Eli's Hospice Insider

Published on Tue Jul 16, 2013 PDF

Medicare Administrative Contractor LCDs won’t save you.

Authorities have been sounding the horn about using non-specific diagnoses improperly lately. But Medicare’s proposed hospice payment rule for 2014 is the first time the Centers for Medicare & Medicaid Services has said hospices shouldn’t be using them at all, believes hospice expert Terri Maxwell with Weatherbee Resources in Hyannis, Mass.

It’s an interesting “clarification” from CMS (see related story, above), since HHH Medicare Administrative Contractor Palmetto GBA has an entire Local Coverage Determination (LCD) for adult failure to thrive in hospice, Maxwell points out.

And the other three MACs have a portion of their “Determining terminal prognosis” LCDs devoted to showing the terminal decline in a patient when there may not be a disease process that stands out as the terminal diagnosis, notes Annette Lee with consulting firm Provider Insights. Lee worked for a MAC for 12 years.

CMS response: In the May 8 Open Door Forum for home care providers, CMS said it realized that MACs have these LCDs. Instructions from CMS “supersede any local policy,” a CMS official said in the forum.

Despite CMS’s claims that it’s just sticking with ICD-9 coding guidance, “the proposed rule actually promotes an incorrect approach to coding,” maintains Judy Adams with Adams Home Care Consulting in Asheville, N.C. “Rather than eliminating debility and adult failure to thrive as a primary diagnosis, the emphasis should be on including all other conditions that contribute to this terminal condition as co-morbidities, but are not themselves the primary cause of the terminal condition.”

How it works: “Under coding guidelines, a non-specific code may be used when there is no clearly identified condition that caused the problem,” Adams explains. “It is actually the cumulative effects of multiple chronic conditions that results in the use of these diagnoses.” This especially applies when multiple other conditions contribute to the terminal illness, but there is no one condition that is most related to the terminal illness, she says. “In other words, the multiple chronic conditions contribute to the terminal condition, but no one condition can be stated as ‘most related’ to the terminal illness, leaving the unspecified debility or adult failure to thrive as the most appropriate primary diagnosis.”

In the forum, Katie Wehri with the National Association for Home Care & Hospice asked CMS how hospices should handle cases that really have debility or AFTT as the primary diagnosis. “According to the ICD-9 coding conventions, those two diagnoses can be used if another prevalent diagnosis is not present,” Wehri said. “When that claim is RTP’d to the provider for additional diagnoses, and there are not any that the provider can add, can you share with us how you anticipate handling those situations?”

Agencies should talk to the certifying physician to determine another primary diagnosis, a CMS official said.

Access Could Be A Problem

CMS says in the rule that beneficiaries’ access to hospice shouldn’t be threatened because the agency is just reiterating ICD-9 guidance that is already in effect. But hospices may be reluctant to admit patients who they formerly assessed as qualifying under the failure to thrive LCD if they can’t figure out how to pick another primary diagnosis and have the patient fit the criteria under that LCD, Maxwell fears.

“These codes really are for patients who are old and frail,” Maxwell says. “What do we do for them?”

On the bright side: It may actually be good news that CMS will put in place edits to return claims with debility and adult failure to thrive as primary diagnoses, Maxwell says. That’s because hospices can fix the problem and still obtain payment, rather than losing it in medical review a year or two after the fact.

And many hospices already have been reducing the number of claims they submit with these non-specific diagnoses as well, since MACs have been implementing edits for them, Maxwell adds.

Another plus: Hospices do have an advantage compared to other providers, “because they employ their own medical directors who can provide those diagnoses,” Lee notes.

Timeline: CMS has not yet issued an effective date for the edits that will return hospice claims with AFTT or debility as principal diagnoses.