Part B Insider (Multispecialty) Coding Alert

CMS wants more documentation from certifying doctors.

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

In its latest proposed rule on hospice payment, CMS shows just how influential the Medicare Payment Advisory Commission can be by proposing adoption of some of MedPACs recent suggestions for the industry.

In an April 24 Federal Register notice, 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 patients 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 physicians responsibility to set out the clinical basis for the terminal prognosis indicated in the patients 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.

But securing the statement could 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 physicians documentation burden is always looked at with disfavor, says Sheree Comer, the Home Health & Hospice Manager at St. Johns Lutheran Hospital in Libby, Mont.

Hospices will have some physician education ahead of them if the rule goes through, Comer says.

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

Hospices could also be put in a tough spot if the certification statement the physician provides doesnt stand up to medical review. Theyd be on the hook to repay Medicare based on documentation that was out of their control.

Comers 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 dont allow nurse practitioners to certify patients for hospice, but CMS is considering NPs for its home visit requirement. 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.

CMS also wants to know if requiring the nurse to be uninvolved with the patients care is 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 Federal Register notice is at http://edocket.access.gpo.gov/2009/pdf/E9-9417.pdf. Comments are due by June 22.