Eli's Hospice Insider

New quality measure will be based on claims data.

In the wake of ramped up scrutiny of the hospice industry, much attention is going to how hospices serve patients in the last days of life. Now the Centers for Medicare & Medicaid Services is planning a major overhaul of a discarded quality measure on the topic.

Old way: Since April 2017, hospices have been collecting data in Hospice Item Set Section O for two “Hospice Visits When Death is Imminent” measures — one assesses the percentage of patients receiving at least one visit from registered nurses, physicians, nurse practitioners, or physician assistants in the last three days of life, and one assesses the percentage of patients receiving at least two visits from medical social workers, chaplains or spiritual counselors, licensed practical nurses, or hospice aides in the last seven days of life. In August 2019, the three-day measure went up on Hospice Compare, but CMS did not follow through with including the seven-day measure on the outcomes, comparison site (see Hospice Insider by AAPC, Vol. 12, No. 11).

New way: Now CMS is “proposing to replace the current Hospice Visits when Death is Imminent measure pair from the HQRP measure set with a modified version, Hospice Visits in the Last Days of Life (HVLDL) based on Medicare hospice claims data,” the agency says in a supporting statement for an Aug. 13 Federal Register notice about the change. “The proposed HVLDL is a single measure and is based on visits by a RN or Medical Social Worker (MSW) in at least two of the last three days of life,” CMS says.

Hospices should already be pretty used to this measure concept. “The three-day measure is already being calculated and reported on Care Compare,” the new site that rolls up all eight of Medicare’s Care sites, points out Theresa Forster with the National Association for Home Care & Hospice. “It will just be calculated using claims data going forward, as opposed to the data submitted by hospices on the HIS discharge.”

Problem: Hospices have raised concerns with CMS over the fact that the current three-day measure doesn’t include visits from all the Interdisciplinary Group members, NAHC notes. The new measure makes the same exclusion.

CMS reveals further measure specifics in a draft of its HQRP Quality Measure Specifications User’s Manual Version 4.00. For one, the patient must have received the RN and/or MSW visits “non-telephonically,” the manual details.

This should also be familiar to hospices. “Televisits — other than social worker phone calls — are not billed on claims, and therefore, don’t count towards the Service Intensity Add-on, nor would they be picked up for this measure,” explains reimbursement expert M. Aaron Little with BKD in Springfield, Missouri. The hospice payment system gives additional SIA add-on payments when an RN or MSW makes an in-person visit in the last seven days of life.

The draft manual specifies that for MSW visits, only “revenue code 056x (other than 0569)” — the code for in-person MSW visits — combined with HCPCS code G0155 (Services of clinical social worker in home health or hospice settings, each 15 minutes) on the claim will count toward the measure. Revenue code 0569 does not count. It indicates “Medical Social Services —Other (phone calls),” HHH Medicare Administrative Contractor CGS explains on its website.

And the measure will exclude patients who:

• “did not expire in hospice care as indicated by reason for discharge,”
• “received any continuous home care, respite care or general inpatient care in the final three days of life,” and
• were enrolled in hospice only one or two days.

Claims Data Is More ‘Accurate And Reliable,’ CMS Says

Why the switch? “Because HVLDL is based on claims data, using it instead of the HVWDII measure reduces the burden of reporting on hospices,” CMS highlights in its supporting statement. CMS proposes to eliminate the Section O HIS items O5000 (Level of Care in final 3 days), O5010 (Number of hospice visits in final 3 days), O5020 (Level of care in final 7 days), and O5030 (Number of hospice visits in 3 to 6 days prior to death), CMS says in its HIS V.3 change table. Eliminating those items will save hospices $6.75 million a year, CMS estimates.

The claims data is also “considered accurate and reliable for measure development, as they are used for payment and subject to audit,” the agency notes.

In data analysis, CMS also discovered that “RN and MSW visits correlate well with the CAHPS quality measures for ‘would recommend’ the hospice,” CMS points out. That was not the case for the second “Hospice Visits When Death is Imminent” measure which never made it onto Hospice Compare.

Interestingly, against stakeholder assumptions, “measure 2 had a negative, or inverse, relationship with the CAHPS ‘would recommend’ measure; that is, decedents of hospices with higher rates for measure 2 were less likely to recommend the hospice,” CMS explains. “When at least two visits from medical social workers, chaplains or spiritual counselors, licensed practical nurses or hospice aides occurred in the last seven days of life (measure 2), the CAHPS ‘would recommend’ measure was significantly lower.”

Medicare may be dumping the seven-day measure for good, Forster predicts. “It does appear that CMS may have given up on the seven-day measure that they’ve been struggling with,” she tells AAPC.

The change also “is better aligned with the Service Intensity Add-on (SIA) policy that became effective January 1, 2016,” CMS adds.

And the new measure “is responsive to the concerns” that the HHS Office of Inspector General and the Medicare Payment Advisory Commission “expressed in recent reports,” CMS adds in its supporting statement.

The comment period closed Oct. 13.

Note: The rule is at www.govinfo.gov/content/pkg/FR-2020-08-13/pdf/2020-17738.pdf. The comment period closed Oct. 13. See the supporting statement, change table, draft updated User’s Manual, and more via a link at www.cms.gov/regulations-and-guidancelegislationpaperworkreductionactof1995pra-listing/cms-10390. More information about the measure, including its lack of National Qualify Forum endorsement, is at https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=6111.