Eli's Hospice Insider

It’s time to kick your diagnosis coding documentation up a notch.

Your payment world is going to look significantly different when the two-tier hospice payment model takes effect Jan. 1. If you don’t start preparing this minute, you may be in for an unpleasant surprise.

Recap: Under the payment model outlined by the Centers for Medicare & Medicaid Services in the Aug. 6 Federal Register, hospices will receive a higher payment ($186.84) for days 1-60 of routine home care, and a lower payment ($146.83) for days 61 and greater of RHC. That compares to the current single $159.34 RHC rate this year (see Eli’s Hospice Insider, Vol. 8, No. 9).

Plus, CMS will pay Service Intensity Add-on payments for RN and Social Work visits in the last seven days of life, up to four hours per day. CMS will pay for SIA visits at the Continuous Home Care rate of $39.44 per hour.

Consider this expert advice to succeed under the first major reform of the hospice benefit since its inception:

• Model to predict your payment impact. Examine your current year stats to see how you’ll fare under the changes. You’ll need to know patient length of stay, the number of patients with service from more than one hospice, and visits by RNs and social workers in the last seven days of a patient’s life, says Judi Lund Person with the National Hospice & Palliative Care Organization. “Staff … in hospice finance will be working to determine the budget implications of the two-tiered payment structure and the SIA payments” using that data, Lund Person tells Eli.

Impact: “For hospice companies listed in the 95th percentile by CMS, which have over 50 percent alive discharges and are over the payment cap, there clearly will be negative consequences in the near term,” warns financial advisory firm Precipio Health Strategies. “CMS is trying to weed out these companies because they question the type of care being delivered or if the patient even meets the criteria to receive hospice care.”

• Set up 60-day detection. Starting Jan. 1, knowing your patients’ hospice care history will be key, thanks to the pay differential based on LOS. “Be sure to understand that the counting of days continues into care provided by a different hospice unless greater than 60 days has passed since the patient revoked or was discharged from the previous hospice,” cautions reimbursement expert Melinda Gaboury of Nashville-based Healthcare Provider Solutions on HPS’ website.

Hospices can access patients’ benefit usage information “through the HIPAA Eligibility Transaction System (HETS),” CMS details in the rule. “The hospice data provided by the Common Working File (CWF) and the HETS system includes the actual start and end date of the hospice benefit days. That information will help hospices determine how many days the hospice benefit was utilized. The HETS system allowable date span is up to 12 months in the past, based on the date the transaction was received. The data return in the HETS system is driven by the date requested in the hospice’s eligibility request.”

Don’t miss: “To ensure that all hospice episodes available in the HETS system are returned, hospices should request a date 12 months prior from the date of the request,” CMS urges.

Alternative: “If a hospice does not have access to the CWF or the HETS system, the hospice can access this data via their MAC’s Portal, the MAC’s Interactive Voice Response (IVR) unit, or request a direct access to the HETS system,” CMS says. “A hospice that uses a clearinghouse may already have access to the HETS system,” CMS adds.

Prepare To Tackle Expanded Coding Duties

Even before the payment model changes take effect, CMS will be requiring you to list all of your patients’ diagnoses on claims starting Oct. 1, according to the final rule. This will be a big change for many hospices, considering that in 2014 about half of hospice claims contained only one diagnosis code.

CMS says it’s not requiring hospices to designate codes as related or unrelated to terminal diagnosis in 2016. But “my bet is that the data will eventually be used to determine if hospices have adequately assumed financial responsibility for everything wrong with the patient,” says consultant Heather Wilson with Weatherbee Resources in Hyannis, Mass., on Weatherbee’s website. “I would imagine a lot of ‘non-hospice’ scrutinizers are going to lend their opinions on the relatedness issues,” she adds.

Heed this expert advice to comply with CMS’s new hospice coding rules, and to prepare for enhanced diagnosis coding impact in future years:

• Beef up assessment. “We are concerned that hospices may not be conducting a comprehensive assessment nor updating the plan of care as articulated by the [Conditions of Participation] to recognize the conditions that affect an individual’s terminal prognosis.” CMS says in the rule.

Hospices should be “certain that they are conducting thorough assessments,” advises Theresa Forster with the National Association for Home Care & Hospice.

• Don’t skimp on diagnosis code inclusion. “ICD–10–CM Coding Guidelines state that diagnoses should be reported that develop subsequently, coexist, or affect the treatment of the individual,” CMS says in the rule.

“Hospices should prepare for the new diagnosis reporting requirements by ensuring that there is a way to collect as many diagnoses as possible in the first days after admission,” Lund Person recommends.

• Document related and non-related diagnoses. CMS says it’s not a requirement to designate codes as related or not at this time, but experts are confident that will be one of the next steps in hospice payment reform.

Hospice providers should go ahead and start “documenting in the patient record which diagnoses are related and which are not” right away, Forster advises. They should also include “their justification for why each non-related diagnosis has been determined to be non-related,” she adds.

Why? “This information will be vital going forward as CMS expands its reviews of spending outside the hospice benefit to determine whether a service is related,” Forster predicts.