Eli's Hospice Insider

CMS wants more documentation from certifying docs.

Get ready for your physicianrelated burden to increase, if a Medicare proposal becomes final.

In the April 24 Federal Register proposed hospice payment rule, CMS proposes a requirement for physicians who are certifying terminal illness for hospice patients to include a "brief narrative explanation of the clinical findings that support a life expectancy of [six] months or less."

The narrative would be typed or written on the certification form itself, CMS says. "An attachment could easily be prepared by someone other than the physician," the agency points out.

Certifying physicians would "synthesize in a few sentences the clinical aspects of the patient's condition that support the prognosis," CMS explains in the proposed rule. "We believe that such a requirement ... would encourage greater physician engagement in the certification and recertification process by focusing attention on the physician's responsibility to set out the clinical basis for the terminal prognosis indicated in the patient's medical record."

Bright side: The proposal has some positive points, notes Dan Hull with Utah Hospice & Palliative Care Organization. "In some ways it is good so that the physicians are more involved in all agencies," Hull says. "It could cause some patients from being admitted if they are really borderline," he adds.

Securing the statement could, however, be a big hassle.

"Requiring this statement could be both administratively and logistically challenging to obtain, especially for smaller providers," worries Judy Brunger with trade group The Carolinas Center for Hospice and End of Life Care.

"Anything that adds to the physician's documentation burden is always looked at with disfavor," says Sheree Comer, the Home Health & Hospice Manager at St. John's Lutheran Hospital in Libby, Mont.

Hospices will have some physician education ahead of them if the requirement goes through, Comer points out.

Brunger hopes CMS revises its proposal to require the statement only for recerts, she tells Eli.

Hospices could also be put in a tough spot if the cert statement the physician provides doesn't stand up to medical review. In that case, they'd be on the hook to repay Medicare based on documentation that was out of their control.

Comer's hospice has had a similar problem with private insurance companies, she notes.

CMS also uses the proposed rule to gather industry feedback on more long-range ideas, including a suggestion to require a hospice physician or "advance practice nurse" to visit hospice patients at the 180-day recert and every recert afterward.

This change would increase accountability in the recertification process, MedPAC suggests.

Wrinkle: Medicare regulations don't allow nurse practitioners to certify patients for hospice, but CMS is considering NPs for its home visit requirement due to practicality, it appears. "A recertification visit to a hospice patient by a nurse practitioner would not relieve the physician of his or her legal responsibility to recertify the terminal illness of such [a] hospice patient," CMS cautions in the rule.

The agency also wants to know if requiring the nurse to be uninvolved with the patient's care would be a good idea. "Seeing the patient on recerts is a good practice, but it will cost a ton more and require small agencies with very part-time medical directors to work hard to meet this requirement," Hull tells Eli. "Utah has about 40 small agencies so this will create a nightmare."

The impact to a hospice's bottom line would be worrying, agrees Helen Hammer with Home Options Hospice in Kalispell, Mont. "If we are expected to cover the cost of a physician visit each certification period after 180 days, then obviously that is an added cost," she notes. "For some patients, that would ... necessitate ambulance transportation or a physician visit to the home, both of which are more costly than the average office appointment."

Even if Medicare would pay separately for a home visit, the payment rate probably wouldn't cover the cost of the visit in rural areas due to mileage and time, notes Dianne Hansen with Partners In Home Care Inc. in Missoula, Mont.

Note: The Federal Register notice is at http://edocket.access.gpo.gov/2009/pdf/E9-9417.pdf. Comments are due by June 22.