nhpco ctc 2012 terri maxwell phd, aprn vp, strategic initiatives weatherbee resources, inc. hospice...

NHPCO CTC 2012

Terri Maxwell PhD, APRNVP, Strategic Initiatives

Weatherbee Resources, Inc.Hospice Education Network, Inc.

Disease-Specific Hospice Eligibility and Recertification Assessment and

Documentation

DISCLOSURE

• Presenter discloses no financial relationships with a commercial entity producing healthcare-related products and/or services.

• This presentation is for educational and informational purposes only. It is not intended to provide legal, technical or other professional services or advice.

OBJECTIVES

At the end of this session, participants will be able to:

1. Identify and utilize the correct LCD, based on the patient’s terminal diagnosis

2. Describe clinical documentation criteria that supports disease-specific clinical eligibility

3. Name the clinical data points necessary to substantiate hospice eligibility for dementia, debility, and cardiopulmonary conditions.

4. Identify “secondary” and” comorbid” conditions associated with common disease states

ELIGIBILITY

• Medicare hospice coverage depends upon a physician’s certification of a life expectancy of 6 months or less if the terminal illness runs its normal course

ELIGIBILITY, CONT’D

•The physician’s clinical judgment must be supported by “clinical information and other documentation” that provide a basis for a life expectancy of six months or less

•Medical necessity must be evaluated and clearly and objectively documented in the clinical record


• Recognizing that determination of life expectancy during the course of a terminal illness is difficult, CMS established LCD guidelines (“medical criteria”) for determining prognosis for cancer and non-cancer diagnoses

• LCD= “Local Coverage Determination”


• LCD guidelines– Created to assist in determining eligibility

based upon disease severity and burden of illness.

– Allows for decline of the beneficiary’s condition be to a factor in determining prognosis.

– Many do not reflect current research or medical information on prognosis.


• Hospice coverage for patients not meeting LCD guidelines may be denied– Some patients may not meet the criteria,

yet are deemed “hospice appropriate” because of co-morbidities or rapid decline

– Coverage for these patients may be approved on an individual basis

LCD PART I:

Decline in clinical status guidelines:

Appropriate for all diagnoses• Clinical status: weight loss, infections, ↓ albumen or cholesterol, dysphagia• Symptoms: dyspnea, cough, poorly controlled nausea, diarrhea, increasing pain• Signs: ↓BP, ascites, edema, pleural effusion, weakness, Change in LOC

PART I, CONT’D

• Laboratory: ↑pCO2, ↓pO2, ↓O2 sat, etc.• KPS or PPS < 70%• ↑ ER or physician visits, ↑ hospitalizations• FAST score 7A or >• ↑ dependence for ADLs• Stage III-IV pressure ulcers

PART II

• Non-disease specific baseline guidelines – both A and B both A and B shouldshould be met be metA. Physiologic impairment of functional status

as demonstrated by: • Karnofsky Performance Status (KPS) or

Palliative Performance Score (PPS) < 70% (HIV Disease, Stroke and Coma establish a lower qualifying KPS or PPS).

B. Dependence on assistance for 2 or more activities of daily living (ADLs)

PART II, CONT’D

NOTE: The baseline guidelines (Part II) do not NOTE: The baseline guidelines (Part II) do not independently qualify a patient for hospice independently qualify a patient for hospice

coveragecoverage.

COMORBIDITIES

Although not the primary hospice diagnosis, the presence of diseases such as the following, the severity of which is likely to contribute to a life expectancy of six months or less, should be considered in determining hospice eligibility:

PART II/IIICOMORBIDITIES

• COPD• CHF• Ischemic Heart Disease• DM• Neurologic (CVA. ALS, MS, Parkinson’s)• Renal• Liver• Cancer• AIDS• Dementia

PART III: NGS, CGS, NHIC DISEASE-SPECIFIC GUIDELINES

• Cancer• ALS• Alzheimer’s and related disorders• Heart disease*•Pulmonary disease*• HIV• Liver disease•Renal disease• Stroke or Coma

Palmetto DISEASE-SPECIFIC GUIDELINES

• Cancer• ALS• Alzheimer’s Dementia • Cardiopulmonary• HIV• Liver disease• Renal care• Neurological Conditions

DOCUMENTATION

• All certification (admission) and recertification documentation must contain enough information to support the patient’s terminal status upon review (by an outside party such NGS, CGS, Palmetto).

• All clinical indicators of decline that form the basis for certifying / recertifying the patient should be documented.

DOCUMENTATION, CONT’D

• Recertification for hospice care requires the same clinical standards be met as for initial certification.

• Documentation should “paint a picture” of why / how the patient is appropriate for hospice as well as the level of care being provided.

• Documentation should include observations and measurable data, not merely conclusions.


• Patients with…long term survival in hospice, or apparent stability, can still be eligible for hospice benefits.

• If this is the case, sufficient justification for a less than 6-month prognosis should appear in the record.

• Inconsistent documentation should be specifically addressed and explained, including findings suggestive of a > 6-month prognosis.

CASE EXAMPLE

Mrs. Turner is an 88 yr. old with a diagnosis of dementia. She weighs 92 lbs., eats little and is totally dependent in all ADLs. She’s not speaking and is sleeping a lot. She was hospitalized two weeks ago for a UTI.

Is she hospice appropriate?

Terminal vs. Custodial Conditions

• A 265 lb man who is losing weight does not equate with terminal frailty, even if he is disabled.

• Gradual worsening of cognition or ADL status or periodic behavioral issues in patients with dementia- in the absence of choking/aspiration, Stage III/IV pressure ulcers, etc.

• Refer to specific requirements in the LCD guidelines to help guide prognostication.

Terminal vs. Custodial

“Is this patient receiving terminal or custodial care?”

•If your documentation doesn’t reflect a 6 month or less prognosis (usually evidenced by clinical decline) you are at risk for payment denial.

•Don’t wait until the recertification date to discharge an ineligible patient.

Distinguishing Chronically from Terminally Ill

“There was no indication in the submitted documentation that beneficiary’s life expectancy was 6 months or less. There was no documentation of co morbidities that would have contributed to a short life expectancy. The documentation shows that the patient required full time custodial care, but not the services of Hospice”.

Comments extracted from a de-identified ZPIC finding


• There are patients for whom a particular LCD guideline does not match; and/or

• An LCD may be inadequate to predict the terminal prognosis of an individual patient who meets the guideline at the SOC and continues to do so over a prolonged period (> than 6 months).

• In such cases, it is important to use Part I: Decline in clinical status guidelines to document all factors that support the terminal prognosis.

DOCUMENTING ELIGIBILITY FOR DEBILITY

• General Decline: – Patients demonstrating significant functional and

nutritional decline that cannot be attributed to a primary clinical condition. (ICD9 is Adult Failure to Thrive)

• General Decline: Use Part 1 Guidelines– General decline patients should have low levels of

function (KPS/PPS 40-50%)– Decline in a specific condition (ex. Alzheimer’s) which

doesn’t meet that condition’s eligibility criteria should not be admitted as “general decline”.

DOCUMENTING ELIGIBILITY FOR DEBILITY: Recommendation

• If there are multiple major medical problems present, choose one of them as a primary diagnosis.– Use the remaining co-morbids to support a poor

prognosis– Document clinical decline as supporting data

• This may be preferable to having a lot of patients on under “general debility”.

BEGINNING THE ASSESSMENT: HOSPICE REFERRAL

• What prompted your call today?– Identify the precipitating event resulting in

hospice referral now

• How has the patient changed over the past 12 months?– Establish baseline and illness trajectory

(type and momentum)

ANSWER THE QUESTION: WHY HOSPICE? WHY NOW?

• What triggered the referral?– Change in condition?– Hospitalization?– New or worsening symptoms?– New or worsening co-morbidity?– Need for additional care?– Change in cg status or setting of care?

ENVIRONMENT OF CARE

Environmental issues that facilitate or impede care• Caregiver availability• Caregiver ability• Adaptive equipment• Financial issues• High/low intensity of available healthcare

providers

BURDEN OF ILLNESS AND “NORMAL COURSE OF ILLNESS”

Burden of illness and factors that influence the

“normal course” of illness• Inter-related secondary and comorbid

conditions• Advanced age• Degree of frailty• Environment of care• Access to other healthcare providers

CLINICAL ELIGIBILITY

The clinical presentation for determining terminal status should include the following:

• Impairment in the structure and function of body systems

• Decline in activity and functional status• Secondary conditions• Comorbid conditions

SECONDARY CONDITIONS

Conditions that are directly related to and occur as a result of the primary condition

SECONDARY CONDITIONS

Examples of conditions that are directly related to

the terminal illness: • Dysphagia is a secondary condition of dementia• Dyspnea is a secondary condition of CHF

Examples of a conditions that manifest as a result

of the terminal condition:• Decubitus ulcer is a secondary condition of coma• Pneumonia is a secondary condition of ALS

COMORBID CONDITIONS

Diseases or conditions that are distinct from the primary

diagnosis, but may contribute to the patient’s life

expectancy.• The terminal diagnosis of Alzheimer’s Disease with

comorbidities of Rheumatoid Arthritis and Diabetes

• The terminal diagnosis of CHF with comorbid COPD

• The terminal diagnosis of FTT with comorbid renal insufficiency

• When supporting prognosis: It isn’t the number of co-morbid conditions but the severity that counts.

HOSPICE PATIENTS – DISEASE TRAJECTORIES

RAPID DECLINE

– Cancer

SAW-TOOTHED DECLINE– Organ system failures

(COPD, Heart Failure, etc.)

SLOW INSIDIOUS DECLINE– Neurodegenerative

disorders– Dementia– Debility

Resource: Field MJ, Cassel CK (eds), Institute of Medicine. Approaching Death: Improving Care at the End-of-life. Washington, DC: National Academy Press. 1997

He

alth

Sta

tus

Death

Time

Decline

TRAJECTORIES OF ILLNESS TO DEATH:

Predictable Terminal Phase

Illnesses such as cancer have a progression that ends in a steady inexorable decline in function until death

•Resource: Field MJ, Cassel CK (eds), Institute of Medicine. Approaching Death: Improving Care at the End-of-life. Washington, DC: National Academy Press. 1997

• He

alth

Sta

tus

•Death

•Time

• Decline: Short period

of evident decline

CANCER DIAGNOSESEligibility Criteria

Documentation must demonstrate that the patient meets • Part II Non-disease specific baseline

guidelines

AND• Cancer guidelines in Part III/appendix

PLUS• Comorbid conditions in Part II/III, if

applicable

CANCER Eligibility Criteria, CONT’D

• KPS or PPS < 70%• Dependent in 2/6 ADLs• Metastases at presentation OR• Progression from an earlier stage of disease to

metastatic disease with either– A continued decline in spite of therapy; or– Patient declines further directed therapy.

Note: Certain cancers with poor prognoses (e.g., small cell lung, brain and pancreatic cancer) may be hospice eligible without fulfilling the other criteria.

REFERRAL # 1

1. Mr. Jones:• DX: Glioblastoma • Age: 46• Residence: Home• PCG: Wife (3 children, all under 7 yrs old)• PTA: On the job injury; PMH is unremarkable;

6’3”; 235 #; BMI = 29% (overweight)• Secondary Conditions: Headache, dizziness,

nausea. Co-Morbid Conditions- None

ADMISSION NOTE

• S – Pt reports, “I can’t believe this is happening. I get hit in the head and find out that I have a tumor. My doctor says the chemo and radiation treatments are no longer working. How is my wife going to cope with three kids by herself? My head’s throbbing, I can’t focus my eyes, and I want to throw up all the time. What am I going to do?”

• O – Pt in darkened room, holding head in both hands and grimacing at slightest noise

ADMISSION NOTE, CONT’D

• Admitted 4/18/12 w/ Glioblastoma. Fully and completely meets Medicare eligibility:– Terminal diagnosis– Life expectancy of six months or less if the

disease runs its normal course (as certified by the pt’s attending and hospice physician)

– Opting for a palliative rather than curative approach to end-of-life care (per hospice election and advance directives)

MEASURABLE DATA POINTS

Pt: Mr. Jones DX: Glioblastoma SOC: 4/18/12MEASURE PTA 4/18/12

Weight / BMI (5’10”) - 235 / 33.7%

KPS/PPS - 70%

NYHA or FAST - N/A

ADLs Independent Independent

Skin Intact Intact

Infection - -

TRAJECTORY OF ILLNESS:Prolonged Insidious Progression

Typical course of debility, Alzheimer’s and related

disorders, Stroke & Coma, etc.

Steady progressive disability leading to

death


Hea

lth S

tatu

sDeath

Time

Decline: prolonged dwindling

DEMENTIA

• Irreversible, progressive brain disease that slowly destroys memory, thinking, and motor skills.

• Caused by various diseases and conditions

DEMENTIA SUBTYPES

• Alzheimer's- – Most common type

• 60-80% of cases– Results from deposits of protein plaques and

tangles in the brain

• Vascular dementia (multi-infarct dementia) – 15-30% cases

RISK FACTORS FOR VASCULAR DEMENTIA

• Hypertension

• Peripheral arterial disease

• Diabetes mellitus

NOTE: When a patient is admitted to hospice with vascular dementia, the conditions above are generally considered “related” and their associated therapies should be covered by hospice

DEMENTIA SUBTYPES CONT’D

• Lewy Body dementia– 10-15% cases

• Frontotemporal dementia – <1% cases

• Parkinson’s Disease w/ dementia– Occurs in 20-40% of patients with PD

– Risk rises in patients with PD for > 8 yrs

Natural History of AD Progression

Olson, 2003

ALZHEIMER’S & RELATED DISORDERS

GUIDELINES

Patient’s with Alzheimer’s Disease should have:

• KPS or PPS < 70%• Minimally dependent in 2/6 ADLs• FAST score of 7 or beyond and one of the

following w/in past 12 months:

ALZHEIMER’S, CONT’D

• Aspiration pneumonia;• Pyelonephritis;• Septicemia;• Multiple stage 3-4 Decubitus ulcers;• Fever, recurrent after antibiotics;• 10% weight loss during previous six months OR

serum albumin < 2.5gm/dl.

FUNCTIONAL ASSESSMENT SCALE “FAST”

• Stage 7: Loss of speech, locomotion, and consciousness

• Sub-stages include:– 7a: Ability to speak limited (1-5 words/day)– 7b: All intelligible vocabulary lost– 7c: Non-ambulatory– 7d: Unable to sit up independently– 7e: Unable to smile– 7f: Unable to hold head up

ALZHEIMER’S, CONT’D

• Frequent UTIs as a result of incontinence or Foley catheter placement is insufficient to demonstrate eligibility without at least one other secondary condition.

• Documentation of weight loss OR appetite decline helps to “paint the picture” of decline.

REFERRAL # 2

2. Mrs. Doe:• DX: Dementia • Age: 96• Residence: SNF• PCG: Facility staff; granddaughter• PTA: 10-year dementia history; aspiration

pneumonia; refusing food; 5’9”; 89#; BMI=13% (underweight)

• Secondary: Cachexia & 2 Stage III Decubitus Ulcers

• Comorbid: Cardiac & NIDDM

ADMISSION NOTE

• S – PCG reports, “She’s not talking or looking at me very much these days and I don’t know why or if something is wrong.”

• O – Pt makes minimal eye contact during visit; occasionally turns head when name is called; can verbalize but speech is limited to < 6 words (usually unintelligible / non-meaningful).


• Admitted 4/18/07 w/Dementia. Fully and completely meets LCD guidelines :

– FAST 7a (speech limited to <6 words)– Secondary conditions:

• KPS 40%• Dependent on PCG for 3 of 6 ADLs


– More secondary conditions:

• Stage III wounds• Aspiration pneumonia

– Co-morbid conditions: • Cardiac Disease• Diabetes


Pt: Mrs. Doe DX: Dementia SOC: 2/28/12MEASURE PTA 2/28/12

Weight / BMI (5’8”) - 89 / 13.5%

KPS - 50%

NYHA or FAST - 7a

ADLs Amb, transfer w/1, incontinent of B&B

Amb, transfer w/1, incontinent of B&B

Skin Stage III (R) shoulder, hip & heel

Stage III (R) shoulder, hip & heel

Infection Aspiration pneumonia

-

DECLINE IN HEALTH STATUS(Debility or Adult Failure to Thrive)

• Use Part I of the LCD guideline, addressing as many of the nine domains as appropriate

• Typically characterized by unexplained weight loss, malnutrition and disability severe enough to impact on the patient’s short-term survival

DECLINE IN HEALTH STATUS, CONT’D

• Irreversible progression in the patient’s nutritional impairment / disability despite a trial of therapy (i.e., treatment intended to effect the primary condition responsible for the patient’s clinical presentation)

• The presence of co-morbid conditions may hasten the patient’s clinical progression, which should be identified and documented.


• Nutritional impairment severe enough to impact on weight.

– BMI below 22 kg/m2* – Patient is either declining enteral / parenteral

nutritional support or has not responded to such nutritional support, despite an adequate caloric intake

*BMI (kg/m2) = 703 x (weight in pounds)

divided by (height in inches)2


• Significant disability demonstrated by a KPS or PPS score of 40% or less

• Both the patient’s BMI and level of disability should be determined using measurements / observations made within the past 6 (rolling) months


• If enteral nutritional support was instituted prior to the hospice election – and will be continued – the BMI and level of disability should be determined using measurements / observations made at the time of the initial certification and at each subsequent recertification.


• Body structure and functional impairment of the digestive system

• Body structure and functional impairment of the neuromusculoskeletal system

• Clinical components Unexplained weight loss Malnutrition Disability

REFERRAL # 3

3. Mr. Adams:• DX: Debility • Age: 85• Residence: SNF• PCG: Facility staff; elderly wife• PTA: weight loss; loss of interest in life; prefers

to stay in bed; requires family assistance with personal care; too weak to walk without 2 people assisting

ADMISSION NOTE

• S – Son reports, “He has lost all interest in life. He’s not eating, he’s losing weight. The pneumonia just took all his energy.”

• O – Pt lethargic; in bed; weight loss AEB baggy pants, belt buckled on tightest hole; incontinent B&B at night; confused; thinks he is at son’s home; stage III wound on (R) hip.


Pt: Mr. Adams DX: Debility SOC: 6/10/12MEASURE PTA 6/10/12

Weight / BMI (5’8”) 150 115 / 17.5%

KPS - 40%

NYHA or FAST - 6e

ADLs Independent Amb with assist, incontinent of B&B

Skin Intact Stage III (R) hip

Infection Pneumonia 4/30/12 -

TRAJECTORY OF ILLNESS:“SAW-TOOTHED”

• Cardio-pulmonary and other organ system failures / conditions (HIV, Liver, Renal, etc.)

• A slow incremental decline punctuated by multiple episodes of acute exacerbations


He

alth

Sta

tus

Death

Time

Decline:never get back to previous baseline

PULMONARY DISEASE GUIDELINES

• The patient with terminal lung disease presents with serious respiratory failure symptoms despite intervention with all the recommended therapies.

• The dying trajectory resembles a “saw tooth,” with periods of compensation, subsequent crisis, followed by compensation until death.

PULMONARY DISEASE, CONT’D

1 and 2 should be present:

1. Severe chronic lung disease with– Disabling dyspnea at rest (e.g., bed to chair

existence, fatigue, cough) – Progression of disease with increased ER visits

and/or hospitalizations for pulmonary infections/respiratory failure, or increased physician visits

2. Hypoxemia at rest with PO2 55mmHg or oxygen saturation < 88%

PULMONARY DISEASE, CONT’D

The following lend support to the terminal prognosis:

• Cor pulmonale (rt-sided heart failure secondary to pulmonary disease)

• Unintentional progressive weight loss of greater than 10% body weight over the preceding six months

• Resting tachycardia > 100/min

PULMONARY DISEASE:Secondary and Comorbid Conditions

Secondary conditions:• Delirium• Pneumonia• Weight loss• Decubitus ulcers• Peptic ulcers

Comorbid conditions:• How do the comorbid conditions impact the

terminal disease trajectory?

REFERRAL # 4

4. Mr. Smith:• Age: 76• DX: COPD • Residence: Home• PCG: Wife• PTA: 56-year smoking history; declines

cessation Rx; 5’9”; 120#; BMI=17.7% (underweight)

• Secondary condition: Cachexia, dyspnea, cough

• Comorbid condition: Hypertension


Pt: Mr. Smith DX: COPD SOC: 9/20/12MEASURE PTA 9/20/12

Weight / BMI (5’9”) 140 120 / 17.7%

KPS/PPS - 50%

NYHA or FAST - -

ADLs - Amb, transfer, dressing and bathing

Skin - -

Infection Pneumonia -

Oxygen PRN 3L cont / 90%

ADMISSION NOTE

• S – Pt reports, “I can’t do anything anymore and I’m totally exhausted all of the time. I can’t catch my breath, even when I’m sitting doing nothing.”

• O – Using accessory muscles & purse-lipped breathing; push of speech noted; dyspnea @ rest; amb X 50 feet w/o rest 2 months ago; now rests 5-10 min after only 10 feet; uses W/C with PCG assist to maneuver in house (too weak to self-propel); O2 @ 3L via NC; sat = 88% RA.


• Admitted 2/20/12 w/COPD. Fully and completely meets Pulmonary Disease LCD guidelines:

– Structural and Functional Limitations• KPS 50%• Dependent on PCG for 4 of 6 ADLs• Impaired mobility


• Impaired respiratory function• Dyspnea at rest• Purse-lipped breathing• Push of speech• O2 sat = 88% RA• Resting tachycardia > 100/min


Secondary conditions:

• Pneumonia• Bed-to-chair existence• Extreme fatigue• Productive cough• Dyspnea with poor response to medication• Oxygen-dependent


Prior to hospice admit:

• Increasing MD & ER visits w/hospitalization for infections

• Respiratory failure (6/28/12)

Additional supporting documentation:• Unintentional progressive weight loss of >

10% of total body weight over last 6 months

Heart Disease

• Heart failure: Progressive disorder resulting from an underlying disease causing structural or functional damage to the heart– Weakening the heart’s pumping function

HEART DISEASE GUIDELINES

• Patient has been optimally treated for heart disease, or is not a candidate or declines surgical procedures. (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease.)

• Exhibit NYHA Class IV disease.• Ejection fraction of < 20% (Note: not required if

not available)

New York Heart Association (NYHA) Classification

HEART DISEASE, CONT’D

• The following are not required, but help to establish hospice eligibility:– Treatment-resistant symptomatic SVT;– History of cardiac arrest or resuscitation;– History of unexplained syncope;– Brain embolism of cardiac origin; and – Concomitant HIV disease

HEART DISEASE, CONT’D

The patient with terminal heart failure has refractory heart failure and serious heart failure symptoms remain, despite using all recommended therapies.

The terminal disease trajectory resembles a“saw tooth” with periods of compensation,subsequent crisis, followed by compensationuntil death.

HEART DISEASE: Comorbid and Secondary Conditions

Comorbid conditions:• How does the comorbid condition impact the

terminal disease trajectory?

Secondary conditions:• Dypsnea• Depression• Pneumonia• Renal failure• Venous stasis ulcers

HEART DISEASE:Eligibility Assessment

• 75 yo male with HX CAD; post-hospitalization following M.I.

• Optimally treated with Lisinopril, Lasix, and Digoxin; • Resting vital signs: 100/52 - 88 – 22;• Supplemental oxygen continuously at 2 liters via nasal

cannula. • C/O feeling tired all the time; “winded”, able to ambulate

10 feet with 5 min recovery time. • Loss of 10 pounds in past month. Normal weight: 175

pounds; current weight: 165 pounds; height 5’10”; BMI: 23.7.

• 2-3+ pitting edema BLE• Ejection fraction: 20% during last hospitalization


• Admitted 5/25/12 w/HF. Fully and completely meets Heart Disease LCD guidelines:

– Structural and Functional Limitations• NYHA Class IV optimally treated w/

significant symptoms at rest • KPS 50%• Dependent on PCG for 4 of 6 ADLs• O2 dependent

Diagnoses without an LCD guideline

• There are patients for whom there is no particular LCD guideline: or

• The LCD guideline does not match and/or

• An LCD guideline may be inadequate to predict the terminal prognosis of an individual patient who meets the guideline at the SOC and continues to do so over a prolonged period (> than 6 months)

Diagnoses without an LCD, CONT’D

• In these cases, it is important to document all factors

that support the terminal prognosis:– functional status– secondary conditions– comorbid conditions

• The documentation should paint a picture of terminality, as opposed to chronicity•Ongoing documentation of decline is required for recertification

Interdisciplinary Group Meetings

During IDG meetings (and outside of IDG meetings), all patients should be assessed to ensure that they continue to meet the LCDs. Remember to check with the patient’s Hospice Aide or volunteer about changes in functional abilities.

Explain periods of stability for specific disease processes:

• “Ms. X is experiencing the ‘saw tooth trajectory’ that is common with congestive heart failure; however, she has declined since 12/21/11, as evidenced by her decline in functional status, and her continued lower extremity edema despite an increase in Lasix.”

RECERT DOCUMENTATION

RECERTIFICATION

• Per LCD guidelines:– Decline in status from admission is not

necessarily required unless it is part of the LCD or rapid decline was part of the initial certification.

– If this is the case, sufficient justification for a less than 6-month prognosis should be documented in the record.

– Inconsistent documentation should be specifically addressed and explained, including findings suggestive of a > 6-month prognosis.

RECERTIFICATION, , CONT’D

– There are patients for whom a particular LCD guideline does not match; and/or

– An LCD may be inadequate to predict the terminal prognosis of an individual patient who meets the guideline at the SOC and continues to do so over a prolonged period (> than 6 months)

– In these cases, it is important to document all factors that support the terminal prognosis

RECERTIFICATION, , CONT’D

– Recertification for hospice care requires the same clinical standards be met as for initial certification

– Documentation should “paint a picture” of how/why the patient is appropriate for hospice as well as the level of care being provided

– Documentation should include observations and measurable data, not merely conclusions.

RECERTIFICATION, CONT’D

• All certification (admission) and recertification documentation must contain enough information to support the patient’s terminal status upon review

• All clinical indicators of decline that form the basis for certifying / recertifying the patient must be documented:– By the IDG (not just nurses)– At every visit


• Document:– Physician & IDG discussions and decisions,

especially with regard to hospice eligibility

– “Related” and “unrelated” conditions

– Progress toward goals


• At recertification, all patients should be considered in light of:– Appropriateness

• Are interventions, behaviors and choices palliative in nature and consistent with the hospice philosophy and plan of care?

– Eligibility• Does the disease trajectory (pattern and

momentum of decline) still reflect a terminal condition?


• All patients, especially those with non-cancer diagnoses, should be assessed for:– Hospitalization risk– Recertification potential – Possible discharge

• A patient does not become ineligible overnight• Discharge is a process not an event• A period of stability must be assessed in light

of its potential to continue


• Use LCD guidelines• Tell the story / paint the picture in words• Document for someone who does not know pt• Support ongoing hospice eligibility & limited

prognosis• What are the palliative treatments that hospice

is providing?• Documentation must stand alone• Compare to baseline data (decline over time)• Visit notes / assessments support eligibility• Describe the “normal” course of illness for the

individual patient


• Eligibility, cont’d.– Are clinically significant secondar /comorbid

conditions present?• If yes, what are they and how do they impact

limited prognosis?

– What is the patient’s overall burden of illness?– What other variables are influencing the

“normal course” of illness for this patient?– Does patient still meet LCD guidelines?

• If yes, how?• If no, what now, why and when?

CHALLENGES

• Ensure that documentation in the clinical record, at admission and recertification is:

– Sufficient and consistent across all disciplines (including physicians), visits, assessments, and IDG meeting notes

– Based on current LCDs– Supportive of hospice appropriateness and

eligibility (limited prognosis)

DETERMINATIONS

IDG DECISION IDG ACTION

1. Pt fully & completely meets LCD guidelines

Recertify – Document how pt meets LCD (CGS: Specify Part I, or Parts II and III combined).

2. Pt partially meets LCD guidelines

If pt has documented symptomatic secondary/comorbid conditions sufficient to support limited life expectancy, recertify (document as noted above).

3. Pt partially meets LCD guidelines

If pt has NO documented symptomatic secondary/comorbid conditions sufficient to support limited life expectancy, consider “MD Baseline Assessment”, DX change, and/or discharge.

4. Pt does not meet LCD guidelines

Consider “MD Baseline Assessment”, DX change, and/or discharge.

If the Patient no longer meets the LCDs…

• Consider a physician baseline assessment• Does the patient meet criteria for another LCD; if so,

change the diagnosis• Physician order for new diagnosis• Physician Narrative• New plan of care• Change billing codes

• Discharge the patient• Discharge should not be a surprise, the patient should

be aware of the potential for discharge if they “stabilize” or become “chronic”

• Custodial care patients are not necessarily terminal• Do not wait for the end of the certification period• The patient has a right to appeal the discharge

Recert Case Example

1. Ms. Doe:• DX: Dementia • Age: 96• Residence: SNF• PCG: Facility staff; granddaughter• PTA: 20-year dementia history; aspiration

pneumonia; refusing food; 5‘9”; 89#; BMI=13% (underweight)

• Comorbid Conditions: Cardiac & NIDDM• Secondary Conditions: None

RECERTIFICATION: MRS. DOEDX: Alzheimer’s disease

DATA PTA SOC1ST

RECERT2nd

RECERT

KPS / PPS - 50% 50% 50%

FAST - 7a 7a 7a

NYHA - N/A N/A N/A

ADLs 3:6 3:6 3:6 3:6

Skin 3 Stage III 3 Stage III Intact Stage II

Wt (5’8”) - 89 95 89

BMI - 13.5% 14.4% 13.5%

Infection Pneumonia - -Cough,

congestion

O2 - - - -

Mrs. Doe Clinical Documentation

Nursing:

dementia AEB ↓ ability to verbalize…speech garbled…inappropriate responses…requires frequent cues to eat…finger foods only…takes one hour to eat meal…loss of six lbs in past month…facility RN indicated pt having congestion, coughing…afebrile

Mrs. Doe Clinical DocumentationSocial Work:

Met w/ family to discuss their financial concerns…application for Medicaid initiated since funds are more limited…spent time with pt…unable to verbalize anything other than repeating “Help me! Help me!” Appears to have lost weight AEB baggy clothes, unable to keep dentures in her mouth…facility nurse reports she is eating less…coughing

Mrs. Doe Clinical Documentation

Volunteer:

Spent time today with Mrs. Doe…unable to communicate except to repeat the words “Help me! Help me!”…assisted her with her lunch- she chewed food but did not swallow…appears to have lost weight

Recert Case Example

2. Mr. Adams:• DX: Debility • Age: 92• Residence: Daughter’s home• PCG: Daughter; granddaughter• PTA: Rapid decline in past 6 months; recent

hospitalization for pneumonia; refusing food; ↓25 lbs; 155#; BMI=24.3% (normal weight)

• Comorbids: CAD, COPD, Dementia• Secondary Conditions: None

RECERTIFICATION: Mr. Adams

DATA PTA SOC1ST

RECERT2nd

RECERT

KPS / PPS - 40% 50% 40%

FAST - 6e 7a 7a

NYHA - N/A N/A N/A

ADLs Indep 2:6 3:6 4:6

Skin Intact Stage III Stage II Intact

Wt (5’8”) - 115 115 125

BMI - 17.5% 17.5% 19%


congestion

O2 - - - -

Mr. AdamsClinical Documentation

Nursing:

Mr. Adams spending 20 hours/day in bed; unable to walk w/o assistance of two; ambulates only 5-10 ft compared to 25 feet last month; HA feeding pt his meals resulting in in wt by 10 lbs; in confusion; speech very limited; mostly unintelligible; cough; congested; temp 101 degrees; will discuss findings with MD


Chaplain:

Visited w/ Mr. Adams; appears more tired today; fell asleep during my 10 min visit; his eyes focused on me but he did not attempt to talk; skin warm to touch; coughing; I called his nurse to discuss my findings; prayed for Mr. Adams before leaving.


Social Worker:

Visited with Mr. Adams today…he was nonresponsive…appeared to be weaker…slept during my visit; his daughter was visiting…she voiced surprise at the change in him since last week…we discussed what to expect as his condition continued to deteriorate.

Recert Case Examples

3. Mr. Smith:• DX: CAD • Age: 75• Residence: ALF• PCG: Facility; wife• PTA: Optimally treated with Lisinopril, Lasix,

and Digoxin; C/O feeling tired all the time; “winded”, able to ambulate 10 feet with 5 min recovery time; ↓10 lbs; 165#; BMI=23.7%

• Comorbids: CAD, COPD, Dementia• Secondary Conditions: None

RECERTIFICATION: Mr. SmithDX: Heart disease

DATA PTA SOC1ST

RECERT2nd

RECERT

KPS / PPS - 40% 50% 40%

FAST - 6a 6a 6b

NYHA - IV IV IV

ADLs Indep 4:6 5:6 5:6

Skin Intact intact intact Stage I

Wt (5’10”) 175 165 160 158

BMI - 25.1% 23.0% 22.7%


congestion

O2 - w/activity Con’t Con’t

Mr. SmithClinical Documentation

Nursing:Pt in bed on arrival; says he is spending most of the time in bed; dyspneic at rest with resp rate of 24 breaths/min; O2 sat is 90% w/ O2 at 4L via NC; drops to 85% w/o O2 for 5 min; febrile with temp 101; lungs congested with wheezes and rhonchi throughout; CXR ordered; started on Levaquin; had difficulty talking d/t dyspnea; c/o feeling weak, tired; no appetite; HA to 5/wk


Social Worker:

It was difficult to converse with Mr. Smith today. He was more SOB and had to stop frequently to catch his breath. Sitting forward in bed leaning over the BST; O2 on continuously; using his inhaler more frequently than usual. Called the nurse to report my findings. She plans to visit him today.


Chaplain:Visited Mr. Smith today but he refused the visit, c/o too tired and SOB. He appeared very SOB and uncomfortable. His wife told me the nurse is on her way. This is the second visit in two weeks in which Mr. Smith appears more short of breath. His wife says he is spending most of his time sitting up in bed or the recliner next to his bed. She reported that he is no longer able to ambulate to the kitchen for his dinner.

Compassion, Care and Eligibility

• Remember… hospice has an obligation to admit, certify and recertify only those patients who meet the guidelines set forth by Medicare (if Medicare is the payer).

• Patients who do not meet the guidelines (e.g. lack a 6 month prognosis) may have the same need as those who do.

• Even though you may want to provide services to these patients, you cannot base eligibility on patient “need” or on the amount of care provided.

QUESTIONS

nhpco ctc 2012 terri maxwell phd, aprn vp, strategic initiatives weatherbee resources, inc. hospice...

Documents

documentation slide

clinical record slide

loc slide

clinical status guidelines

contd lcd guidelines

contd hospice coverage

clinical information

normal course slide