Successful Documentation Tips from CGS€¦ · Successful Documentation Tips from CGS October 23,...

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Successful Documentation Tips from CGSOctober 23, 2017

Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2017 AMA.

Successful

Documentation Tips

from CGSMissouri Hospice & Palliative Care Association

October 23, 2017

Presented by:

Sandy Decker RN BSN

Senior Provider Education Consultant

Hospice Clinical Resources

CMS Hospice Benefit Policy Manual (Pub. 100-02, Chapter 9)

http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/bp102c09.pdf

October 23, 2017 © 2017 Copyright, CGS Administrators, LLC.2

Election Statement of Benefits

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c09.pdf

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Sample Hospice Election Statement

https://www.cms.gov/outreach-and-education/medicare-

learning-network-mln/mlnmattersarticles/downloads/se1631.pdf


Hospice Election Statement Requirements

▪ No standard form for the election statement is required

▪ Each hospice designs and prints their own election statement

▪ An individual (or their representative) must elect hospice care


Election of Hospice Care


https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se1631.pdf

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Election statement must include:

▪ Patient’s choice of attending physician, including (but not limited to),

the physician’s full name

• Should include the physician’s NPI or other identifying information

• The attending physician is the Individual having most significant role in

determination and delivery of care

▪ Patient’s acknowledgement that attending was his/her choice




Changing the Attending Physician

If patient wants to change designated attending physician, patient

must file signed statement with hospice to identify new attending

▪ Enough detail so it’s clear which physician/NP was designated

▪ Include date the change is effective

▪ Patient's dated signature

▪ Acknowledgement that change is patient’s choice


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The election statement must include all of the following:

▪ Identification of the hospice provider

▪ Acknowledgment of the patient’s full understanding of

hospice care, particularly palliative vs. curative care






▪ Patient’s acknowledgment that certain Medicare services are

waived by the election of hospice

• Medicare services for a condition completely unrelated to the

terminal condition for which hospice was elected remain available

to the patient if he or she is eligible for such care


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▪ Effective date of the hospice election

• No earlier than the date of the election statement

▪ Signature of the patient or authorized representative




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The election statement remains in effect as long as the individual:

▪ Remains in the care of a hospice

▪ Does not revoke the election

▪ Is not discharged from the hospice



Common deniable errors include:

▪ No clear understanding of palliative vs. curative care

▪ No clear understanding of waiving certain Medicare services

▪ No effective date of election

▪ Attending physician not identified

▪ No signature

▪ Hospice election form not submitted

Results in full denial


CGS Hospice Coverage Guidelines

www.cgsmedicare.com/hhh/coverage/Hospice_Coverage_Guidelines.html

18 October 23, 2017 © 2017 Copyright, CGS Administrators, LLC.

http://www.cgsmedicare.com/hhh/coverage/Hospice_Coverage_Guidelines.html

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Physician’s Certification and

Recertification

of Terminal Illness

Documentation Requirements


https://www.cms.gov/Outreach-and-Education/Medicare-

Learning-Network-

MLN/MLNMattersArticles/Downloads/SE1628.pdf

Hospice Benefit Periods

When the patient elects hospice, and the physician certifies the

patient is terminally ill, the patient starts their first hospice benefit

period

▪ Two 90-day benefit periods

▪ Unlimited 60-day periods, as long as the patient continues to be

terminal and the physician certifies as such

Note: The patient may have had a previous hospice election


https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1628.pdf

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Certification of Terminal Illness

For initial 90-day benefit period, patient must be certified by:

▪ Hospice medical director OR physician member of the

interdisciplinary group; AND

▪ Patient’s attending physician (if they have one)

• Only a medical doctor or doctor of osteopathy can certify or recertify a

terminal illness


Recertification of Terminal Illness

For all subsequent benefit periods, certification is only required

from the hospice medical director

The patient must continue to meet eligibility criteria


(Re)Certification of Terminal Illness

The written (re)certification of terminal illness must include:

▪ Statement that the patient’s life expectancy is 6 months or less if the

illness runs its normal course

• “I certify that (beneficiary’s name) is terminally ill with a life expectancy of

six months or less if the terminal illness runs its normal course.”

▪ Benefit period exact beginning and ending dates

• Example – July 1, 2017 – August 29, 2017


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Physician’s narrative notes specific, individual clinical findings to

support 6 months or less life expectancy

▪ Specific clinical findings supporting six months or less life

expectancy

▪ Legible, dated signature(s) of physician(s)

▪ Narrative must include statement directly above physician

signature attesting the physician confirms that he/she

composed the narrative based on his/her review of the

patient’s medical record or examination of the patient



Physician’s narrative notes specific, individual clinical findings

to support 6 months or less life expectancy

▪ Cannot contain check boxes or standard language used for all

patients

▪ If narrative is an addendum, the physician also must sign

immediately following narrative in addendum

▪ For recertification narratives associated with the third or later

benefit period, there must be an explanation stating why the

clinical findings of the face-to-face encounter support a life

expectancy of 6 months or less


(Re)Certification: When and Who

Certification/recertifications must be completed:

▪ Up to 15 days before benefit period begins or

▪ No later than 2 calendar days after the first day of each period

• Example:

• First day of benefit period is October 1

• 2 calendar days after the first day of the benefit period would be October 3


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(Re)Certification: When and Who

An oral certification is allowed if a written certification cannot be

obtained, but

▪ The certification/recertification must be signed and dated by the

physician(s) prior to billing Medicare

▪ The oral certification should state the patient is terminally ill, with

a prognosis of 6 months or less.

▪ Hospice staff must make an appropriate entry in the patient’s

medical record as soon as they receive an oral certification.


Certification / Recertification

Common deniable errors include:

▪ Physician narrative does not contain individual clinical information

to support terminal illness

▪ Certification is dated prior to face-to-face encounter (if applicable)

▪ Physician signature not dated

▪ Signed by nurse practitioner



Face-to-Face Encounter

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Face-to-Face

Prior to the third benefit period, and with each subsequent

recertification, beneficiaries must have a documented face-to-face

encounter with a hospice physician or nurse practitioner (NP)

▪ Physician may be hospice employee or contracted

▪ If nurse practitioner (NP), must be hospice employee

Note: All prior hospice elections/benefit periods are counted


Face-to-Face

Face-to-face encounter must occur:

▪ No more than 30 days prior to the recertification date; AND

▪ Prior to certifying physician’s composition of narrative

• Narrative must be based on FTF encounter findings

▪ A face-to-face encounter may occur on the first day of the benefit

period

Note: Recertification window remains 15 days prior to, or by

2nd calendar day after the benefit period begins


Face-to-Face

Exceptional circumstances:

▪ Emergency weekend admission

▪ CMS data systems are unavailable to check prior hospice elections

▪ Rarely allowed

In cases of exceptional circumstances, the face-to-face encounter

up to 2 days after admission will be considered timely

▪ Must be well documented

▪ Show why someone was not available to do the face-to-face

encounter


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Face-to-Face

If a patient dies within 2 days of admission without a FTF

encounter, it will be considered complete


Face-to-Face

Documentation must include:

▪ Physician or NP attestation that FTF occurred and the date it

occurred

• The attestation must have dated signature

• The attestation must be clearly titled

▪ FTF documentation clearly titled


Face-to-Face

▪ If FTF is performed by someone other than the certifying physician,

an included attestation must indicate the clinical findings were

communicated to the certifying physician

▪ Date and legible signature of physician or NP that performed

encounter

• Note: Face-to-face encounter and certification must be signed, along

with certification, prior to billing claim


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Face-to-Face

Common errors include:

▪ Physician signature not dated

▪ No date of encounter

▪ Not timely

▪ No attestation by the physician when encounter performed by the

nurse practitioner

▪ FTF encounter happens after the physician signs the recertification

of terminal illness



Plan of Care

Plan of Care

▪ The IDG must review and update the plan of care at least every

15 days

▪ Submit all IDG meeting documentation that pertain to the dates

of the benefit period being reviewed

• Example: Dates being reviewed – July 1, 2017 – July 31, 2017,

requires documentation for IDG meeting held on June 27, 2017


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Plan of Care


▪ Not all IDG review documentation was submitted to cover all the

dates under review

▪ POC not reviewed at least every 15 days by IDG team

Results in partial or full denial


Documenting Terminal Status

Effective Documentation of Terminal Status

Decisions are reliant upon documentation

Results in a full denial for the submission

Documentation must be legible

Medical necessity is always based on the patient’s condition

▪ Is it the patient or the documentation?

▪ Make the reviewer see the patient

• The reviewer isn’t allowed to read between the lines


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▪ Documentation is expected to show significant changes

in the beneficiary’s condition and plan of care

▪ Always include admission assessment

▪ Decline must be evident in documentation


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Documentation must allow the reviewer to have a mental image of

the patient, especially for long-term hospice patients, or those

with chronic illness and general decline

Use quantifiable values and measurements to show changes

Graphs can show trends, even though the visit to visit changes

may seem minimal


Weight

▪ Document patient’s weight at least monthly and more often if

possible

▪ Take weights in consistent fashion

• Time of day

• Clothing

• Consistency in relation to meal time

▪ Show prior and current weights

• Don’t just say “loss of 4 pounds in since last weighing”


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Measurements

▪ Upper arm/girth/leg measurements starting at admission

• Even if able to weigh patient

• Shows trend if suddenly unable to weigh

▪ Include policy in documentation that shows how and where

measurements are taken

• Be consistent!


Pain

▪ Type of pain

▪ Body language!!!

▪ Document any extenuating circumstances

• Examples: Wound care just completed, ready for pain meds, etc.


Pain

▪ Level of pain

• 0-10 scale is preferable, but may not be workable

• Consistent method of pain measurement is key

▪ Expressed in the way patient/caregiver understands

• Colors

• Small, Medium, Big

• Wong-Baker FACES Pain Rating Scale


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Responsiveness

▪ Does the patient react to your presence?

▪ Is the patient frightened of you?

▪ Does the patient remember you from last visit?

▪ Does the patient remember why you’re there?

▪ Unresponsive

• Respond to touch? Smell? Light?

▪ Fades in and out of alertness?


ADLs

▪ What can they do SAFELY?

▪ Examples – getting in/out of shower, ambulate while carrying food

▪ Are they impulsive?


Vital Signs

▪ Respiration rate, blood pressure, pulse, temperature

▪ Graph easily shows change

▪ Does patient have a response to the procedure?


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Strength

▪ Ask the patient to squeeze your hands

▪ Is there a difference from last visit?

▪ Can the patient raise their hands to yours?

▪ Is the patient able to stand?

▪ Assisted or unassisted

▪ How long?

▪ Safely?


Lucidity

▪ Can the patient carry on a lucid conversation?

▪ If you change the subject abruptly can they still follow along?

▪ Can the patient make decisions?

▪ Simple or complex

▪ Current events

▪ Inside or outside their world


I’s and O’s

▪ Make sure the serving size is appropriate and consistent

▪ Check for dehydration

▪ Is there a system in place to measure output that is workable for the

patient/family?

▪ Is the patient offered food that they like and is appropriate for them?

▪ Appetite persistent or changing?

▪ Decrease in appetite may mean the patient’s dentures no longer fit or

they don’t like what is being served


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Aspiration

▪ Observed? By whom?

▪ Recurrent?

▪ Mild choking vs. aspiration

▪ Aspiration pneumonia must be confirmed by physician


Fatigue

▪ Meet you at the door?

▪ Too tired to get out of chair?

▪ Recurrent?

▪ Too tired for self grooming?

▪ Too tired to prepare food or eat?

▪ No longer does favorite tasks?


Agitation

▪ New

▪ Variable levels

▪ Unable to participate in conversation

▪ New?

▪ Increased?


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Skin

▪ Broken skin vs. fragile skin

▪ Stage wounds whenever possible

▪ Redness?

▪ Itching?

▪ Pale or flushed?

▪ Diaphoretic?



▪ Amount and detail dependent upon situation

• Chronic, deteriorating condition vs. rapid progression

• Chronic, deteriorating condition may depend upon small details

• Rapid progression may be focused on only one symptom



Failing to show “big picture”

▪ Send in relevant documentation outside of period requested

▪ Always send in admission assessments

▪ Remember the reviewer can’t see the person

▪ Chart the obvious

▪ Should be able to identify person from the documentation without

seeing the name


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Use functional scale, as appropriate and always

tell what changed to make change in status

▪ Karnofsky Performance Scale (KPS)

• 30%, 40%, 50%, etc.

• Don’t average numbers

▪ Palliative Performance Scale (PPS)

• 30%, 40%, 50%, etc.

• Don’t average numbers

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October 23, 2017 © 2017 Copyright, CGS Administrators, LLC.

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Use functional scale, as appropriate and always tell what

changed to make change in status

▪ Functional Assessment Staging (FAST)

▪ New York Heart Association (NYHA)

• Should be determined by physician

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Don’t forget documentation from the interdisciplinary group

(IDG) meetings

▪ Information from other staff members

▪ May have different perspectives

▪ Different staff members see patient at different times and in different

circumstances

▪ Example – nurse vs. social worker or chaplain

▪ Aides have valuable information. See patient at most vulnerable.

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▪ Use numbers

▪ Use observations and data, not conclusions

▪ Clinical indicators of decline

• Weight loss, infections, changes in mobility, etc.

▪ Review terminal admitting diagnosis – still appropriate?

▪ Reassessment is ongoing

▪ Remember quality versus quantity




▪ Documentation by various disciplines do not show same level of

decline

▪ No measurable signs/symptoms presented for comparison

▪ Documentation does not support terminal status

▪ Documentation shows hospice benefit being utilized as long-term

care benefit

Results in partial or full denial


Hospice Resources

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Medical Review Standards

CMS Medicare Benefit Policy Manual (CMS Publication 100-02)

▪ Chapter 9 - Hospice

▪ http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/bp102c09.pdf


Resources

CGS HHH Medicare Bulletins

http://www.cgsmedicare.com/hhh/pubs/mb_hhh/index.html

▪ Published monthly (links to prior bulletins)

▪ Compilation of news for hospice and home health providers

CGS ListServ messages

http://www.cgsmedicare.com/hhh/pubs/news/index.html

▪ ‘Recent News’ Web page

▪ Timely access to current news and publications

http://www.cgsmedicare.com/medicare_dynamic/ls/001.asp

▪ Join/Update Listserv


Six Months or Less Terminal Prognosis

http://www.cgsmedicare.com/hhh/coverage/coverage_g

uidelines/hospice_documentation.html


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http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c09.pdf

http://www.cgsmedicare.com/hhh/pubs/mb_hhh/index.html

http://www.cgsmedicare.com/hhh/pubs/news/index.html

http://www.cgsmedicare.com/medicare_dynamic/ls/001.asp

http://www.cgsmedicare.com/hhh/coverage/coverage_guidelines/hospice_documentation.html

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https://cgsmedicare.com/hhh/education/materials/pdf/hospice_do

cumentation_tool.pdf


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http://www.cgsmedicare.com/hhh/education/materials/pdf/ho

spice_clinical_factors_recert_tool_h-020-01_07-2011.pdf


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Resources

CGS Frequently Asked Questions

http://www.cgsmedicare.com/hhh/education/faqs/index.html


https://cgsmedicare.com/hhh/education/materials/pdf/hospice_documentation_tool.pdf

http://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_clinical_factors_recert_tool_h-020-01_07-2011.pdf

http://www.cgsmedicare.com/hhh/education/faqs/index.html

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Questions?

CGS Provider Contact Center: 1.877.299.4500

Option 1: Customer Service

Option 2: Electronic Data Interchange (EDI)

Option 3: Provider Enrollment

Option 4: Overpayment Recovery (OPR)

Twitter: http://www.twitter.com/hhhcgs

Facebook: http://www.facebook.com/hhhcgs

http://www.twitter.com/hhhcgs

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