recertification of the medicare hospice terminal illness · recertification of the medicare hospice...

10
Page 1 of 10 © National Hospice and Palliative Care Organization, Revised December 2013 Recertification of the Medicare Hospice Terminal Illness Compliance for Hospice Providers Revised December 2013 (a) Regulatory Requirements of §418.22 - Recertification of Terminal Illness Recertification of terminal illness is based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness. Source of the Recertification of Terminal Illness No one other than a medical doctor or doctor of osteopathy can certify or re-certify a terminal illness. (§1814(a)(7) of the Social Security Act) The patient’s attending physician and hospice medical director (or hospice physician) must both complete the initial recertification of terminal illness. (CMS, §418.22(c)) Timing of the Recertification of Terminal Illness The second 90-day benefit period, first 60-day benefit period, and subsequent benefit periods: The hospice must obtain written recertification of terminal illness for each benefit period. (418.22(a)(1)). Recertifications may be completed up to 15 days before the start of the new benefit period. If the hospice physician forgets to date the recertification, a notarized statement or some other acceptable documentation can be obtained to verify when the recertification was obtained. The hospice must obtain either the written or oral recertification within 2 calendar days after the first day of each period. (418.22(a)(2)). Compliance Guide National Hospice and Palliative Care Organization Regulatory & Compliance www.nhpco.org/regulatory Recertification of terminal illness The hospice regulations for recertification and recertification are included in the Medicare regulations at 42 CFR 418.22. The Centers for Medicare and Medicaid Services (CMS) made updates to the hospice recertification and recertification regulations between 2005 and 2011 that radically change how a hospice provider completes these processes. The regulatory language appears later in this tip sheet. Note: A nurse practitioner may not certify the patient’s terminal illness even if they will be serving as the patient’s attending physician. (CMS, CR 2750, 2003)

Upload: vanthu

Post on 06-Apr-2019

213 views

Category:

Documents


0 download

TRANSCRIPT

Page 1 of 10 © National Hospice and Palliative Care Organization, Revised December 2013

Recertification of the Medicare Hospice Terminal Illness

Compliance for Hospice Providers Revised December 2013

(a) Regulatory Requirements of §418.22 - Recertification of Terminal Illness Recertification of terminal illness is based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness.

• Source of the Recertification of Terminal Illness

No one other than a medical doctor or doctor of osteopathy can certify or re-certify a terminal illness. (§1814(a)(7) of the Social Security Act)

The patient’s attending physician and hospice medical director (or hospice physician) must both complete the initial recertification of terminal illness. (CMS, §418.22(c))

Timing of the Recertification of Terminal Illness • The second 90-day benefit period, first 60-day benefit period, and subsequent benefit

periods: • The hospice must obtain written recertification of terminal illness for each benefit

period. (418.22(a)(1)). • Recertifications may be completed up to 15 days before the start of the new

benefit period. • If the hospice physician forgets to date the recertification, a notarized statement

or some other acceptable documentation can be obtained to verify when the recertification was obtained.

• The hospice must obtain either the written or oral recertification within 2 calendar days after the first day of each period. (418.22(a)(2)).

Compliance Guide National Hospice and Palliative Care Organization Regulatory & Compliance www.nhpco.org/regulatory

Recertification of terminal illness The hospice regulations for recertification and recertification are included in the Medicare regulations at 42 CFR 418.22. The Centers for Medicare and Medicaid Services (CMS) made updates to the hospice recertification and recertification regulations between 2005 and 2011 that radically change how a hospice provider completes these processes. The regulatory language appears later in this tip sheet.

Note: A nurse practitioner may not certify the patient’s terminal illness even if they will be serving as the

patient’s attending physician. (CMS, CR 2750, 2003)

Page 2 of 10 © National Hospice and Palliative Care Organization, Revised December 2013

• The recertification of terminal illness must be signed by the medical director of the hospice or the physician member of the hospice interdisciplinary group (418.22(c)(1)).

• Oral/ verbal recertification • If the hospice cannot obtain written recertification within 2 calendar days of the

start of care date, it must obtain oral recertification within 2 calendar days. (418.22(a)(3)).

• The oral/ verbal recertification is standing in for the written recertification, so it must contain certain information that is included on the written recertification such as:

Statement that the individual’s medical prognosis is that their life expectancy is 6 months or less if the terminal illness runs its normal course

Benefit period from and through dates that the recertification or recertification covers

Name and credentials of physician who provided the oral/verbal recertification

Name and credentials of hospice staff member receiving the oral/verbal recertification

• The oral/verbal recertification should be obvious in the clinical record. While there is no official regulation that requires an oral/ verbal recertification to be separate from a patent’s plan of care (485 form for example), CMS has stated that it is their preference to see separation of these two pieces of documentation.

• The Medicare hospice regulations do not state that an oral/verbal recertification is a physician order or requires a physician signature. If a hospice provider chooses to treat the oral/verbal recertification as a physician order, then the state regulations pertaining to physician orders must be followed.

Content of the recertification The certification must conform to the following requirements:

• The certification must specify that the individual’s prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course.

• Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification as set forth in paragraph (d)(2) of this section. Initially, the clinical information may be provided verbally, and must be documented in the medical record and included as part of the

For suggested certification form language

See NHPCO’s

Components of the Medicare Hospice Certification and

Recertification Form Guide

Available for download in the NHPCO Regulatory & Compliance Center

www.nhpco.org/regulatory

Page 3 of 10 © National Hospice and Palliative Care Organization, Revised December 2013

hospice’s eligibility assessment.

• The physician narrative statement As of October 1, 2009, the physician’s brief narrative explanation of the clinical

findings that supports a life expectancy of 6 months or less, as part of the certification and recertification forms or as an addendum to the certification and recertification forms.

Only the certifying physician may compose the narrative statement. An NP or nurse may not compose the narrative statement. The narrative statement may not be a reference to “history & physical”

documentation. The narrative must reflect the patient’s individual clinical circumstances. What to include in the physician narrative statement:

The narrative statement is the place where the certifying physician states why the patient is eligible for hospice. Physicians should reference appropriate Local Coverage Determinations (LCDs), prognostic indicators, functional ability scales, symptom management scales that support the patient’s prognosis.

If the primary diagnosis does not have a coordinating LCD, the narrative should state that there is no LCD to support the diagnosis, but that the patient is eligible for hospice as evidenced by… (Prognostic indicators, functional ability scales, symptom management scales, etc…) The physician should also reference the terminal diagnosis and related diagnosis that form the 6 month or less prognosis.

If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician’s signature.

If the narrative exists as an addendum to the certification or recertification form, in addition to the physician’s signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum.

The narrative shall include a statement directly above the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient’s medical record or, if applicable, his or her examination of the patient.

The attestation language should include language that the certifying physician composed the statement.

The narrative statement may be dictated by the certifying physician. The narrative statement cannot contain check boxes or standard language used for

all patients. All certifications must be signed and dated by the certifying physician, and must

include the benefit period from and through dates to which the certification or recertification applies.

The certification may be hand signed or electronically signed. Per CMS CR 8219, the use of a rubber stamp for a signature is in accordance

with the Rehabilitation Act of 1973 in the case of an author with a physical

Page 4 of 10 © National Hospice and Palliative Care Organization, Revised December 2013

disability that can provide proof to a CMS contractor of his/her inability to sign their signature due to their disability.

• Face–to-face encounter

CMS added the face-to-face encounter requirement for recertification of

terminal illness with the third benefit period recertification and every subsequent recertification as part of the Home Health Payment Rule, posted on November 2, 2010.

The face-to-face encounter requirement may apply to patients who are new admissions to a hospice but who may have had hospice services previously from a different hospice.

The hospice should check the CMS Common Working File (CWF) prior to admission to determine whether prospective new patients have received hospice care previously, and provide a face-to-face encounter as part of the recertification process for patients who will be entering their 3rd or subsequent hospice benefit periods.

Note: CMS transition from the CWF to the HIPAA Eligibility Transaction System (HETS) is effective April 1, 2014, unless CMS announces an additional delay in implementation. After that date, the CWF will not be active.

• Face-to-face encounter timing

The face-to-face encounter may be completed up to 30 days before the start of the new benefit period.

A face-to-face encounter may be completed the same day as the hospice admission if necessary.

The last day when a face-to-face encounter can be completed timely is the end of the first day of the new benefit period.

• Who may complete the face-to-face encounter?

A hospice physician or nurse practitioner (NP) may complete the face-to-face encounter.

Hospice physician A ‘‘hospice physician’’ is a physician either employed by or

working under arrangement with a hospice (i.e., contracted). Medical residents or fellows who are rotating through a

hospice may provide the required face-to-face encounter if they are employed by the hospice or are working under contract with the hospice, and if they will be composing the narrative and signing the recertification.

Any hospice physician can perform the face-to-face encounter regardless of whether that same physician recertifies the patient’s terminal illness and composes the recertification narrative.

Nurse Practitioner

Page 5 of 10 © National Hospice and Palliative Care Organization, Revised December 2013

The NP must be an employee of the hospice. • ‘‘Employee means a person who:

o (1) Works for the hospice and for whom the hospice is required to issue a W–2 form on his or her behalf;

o (2) If the hospice is a subdivision of an agency or organization, an employee of the agency or organization who is assigned to the hospice; or (3) is a volunteer under the jurisdiction of the hospice.’’

• Face-to-face attestation statement

The Medicare regulations do not require clinical documentation of the face-

to-face encounter, but for legal purposes, it is highly recommended that the physician or NP completing the face-to-face encounter document a clinical note in the clinical record.

The physician or NP who performs the face-to-face encounter must attest in writing that he or she had a face-to-face encounter with the patient, including the date of that visit.

The attestation statement required text includes: Beneficiaries’ name Date of face-to-face encounter Attestation statement:

o If certifying physician completes the face-to-face encounter, the statement should include that clinical findings of that encounter have been used in determining continued eligibility for hospice care.

o If the to-face encounter was completed by a non-certifying physician or NP, they shall state that the clinical findings of the encounter were provided to the certifying physician, for use in determining hospice eligibility.

The physician or NP’s printed name, signature and date should appear below the face-to-face encounter attestation statement.

• Exceptional circumstances

In cases where a hospice newly admits a patient who is in the third or later

benefit period, exceptional circumstances may prevent a face -to-face encounter prior to the start of the benefit period.

Examples could include but are not limited to: • Patient who is an emergency weekend admission.

Note: The date of the face-to-face

encounter visit and the date the

physician/ NP signs the face-to-face

encounter attestation statement; do not

need to be the same date.

Page 6 of 10 © National Hospice and Palliative Care Organization, Revised December 2013

• CMS data systems are unavailable and the hospice may be unaware that the patient is in the third benefit period.

In such documented cases, a face-to-face encounter which occurs within after the admission date will be considered to be timely. 2 days

• Example – patient is admitted Friday evening; the face-to-face must be completed by Sunday

In documented exceptional cases when the patient dies within 2 days of the admission date without a face-to-face encounter, the face-to-face encounter can be deemed as complete.

• Missed or late face-to-face encounter

If the patient remains eligible for next benefit period but the face-to-face

encounter was missed/ late, the patient ceases to be eligible for the Medicare Hospice Benefit and must be discharged from the Medicare Hospice Benefit.

An NP or physician must complete a face-to-face encounter prior to readmitting the patient back to the Medicare Hospice Benefit.

The re-admission should be treated as a new admission to the Medicare Hospice Benefit.

The physician or NP completes the face-to-face encounter, and signs the face-to-face encounter attestation which includes the patient’s name and the date of the encounter.

Required: If the NP or non-certifying hospice physician completes the face-to-face encounter, he/she communicates the findings to the hospice certifying physician for use in determining eligibility and composing narrative.

• Certifying hospice medical director / hospice physician signs the certificate of terminal illness form.

The certifying hospice medical director / hospice physician composes the brief narrative statement and signs the narrative attestation statement.

Timing of the recertification of terminal illness at a glance

Page 7 of 10 © National Hospice and Palliative Care Organization, Revised December 2013

Recertification of Terminal Illness and Billing • Verify the benefit period: Hospices are responsible for verifying which benefit period a

patient is in at admission by using the CWF or HETs system to determine the beneficiary’s benefit period. Pay particular attention to any benefit periods that the patient has had from other hospices. This can impact the face-to-face encounter from your hospice.

• 3rd or subsequent benefit period: If the patient has received hospice services from your hospice or another hospice prior to this admission, it is a recertification.

If they are entering their 3rd benefit period or later, the hospice is required to provide a face-to-face encounter with the patient by a hospice physician or nurse practitioner as a part of the recertification process.

• Written recertification must be on file in the hospice patient’s record prior to submission of a claim to the fiscal intermediary or Medicare Administrative Contractor (MAC). [Recertification form, physician narrative and attestation statement]

• If the physician forgets to date the recertification, a notarized statement or some other acceptable documentation can be obtained to verify when the recertification was obtained. (Benefit Policy Manual (Internet only manual 100-02, chapter 9, Section 20.1))

• Transfers from one hospice to another hospice: For patient transfers from one hospice to another, the receiving hospice would use

the same recertification date as the previous hospice until the next recertification period. (CMS, Medicare Claims Processing Manual-Chapter 11, 2009)

Maintenance of Records Hospice staff must—

1. Make an appropriate entry in the patient's medical record as soon as they receive an oral recertification; and

2. File written recertifications in the medical record. (§418.22(d), 2005)

Additional Related Resources from NHPCO: • Initial Certification of the Hospice Terminal Illness Compliance Guide, Revised Dec 2013

(Available at http://www.nhpco.org/regulatory/nhpco-developed-tools-and-resources) • Components of the Medicare Hospice Certification and Recertification Form, Dec 2013

(Available at http://www.nhpco.org/regulatory/nhpco-developed-tools-and-resources) • Certification of Terminal Illness Audit Compliance Tool, Dec 2013 (Available at

http://www.nhpco.org/regulatory/nhpco-developed-tools-and-resources) • Certification and Recertification of Hospice Terminal Illness - Maps to Guide Hospice

Admissions (Available in the NHPCO Marketplace, http://www.nhpco.org/marketplace ) • CMS Face –to-Face Final Rule – November 2010

The Medicare Regulations

Page 8 of 10 © National Hospice and Palliative Care Organization, Revised December 2013

The following table outlines the recent regulatory revisions and the implementation year. Recertification regulations Issue date and

Effective date Description and link to regulation

Medicare Program; Hospice Wage Index for Fiscal Year 2010 (CMS–1420–F)

August 6, 2009

October 1, 2009

• Physician narrative requirement for hospice certification/ recertification

• http://edocket.access.gpo.gov/2009/pdf/E9-18553.pdf

Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011; Changes in Certification Requirements for Home Health Agencies and Hospices; Final Rule

November 17, 2010

January 1, 2011

• Hospice face-to-face encounter requirement for hospice recertifications in the 3rd and subsequent benefit periods

• http://www.gpo.gov/fdsys/pkg/FR-2010-11-17/pdf/2010-27778.pdf

Change Request 7337 - New Hospice Certification Requirements and Revised Conditions of Participation (CoPs)

March 2, 2011

January 1, 2011

• Updates to physician narrative statement and face-to-face encounter requirements; updates to selective Conditions of Participation regulations

• https://www.cms.gov/transmittals/downloads/R141BP.pdf

Change Request 7478 - Hospice Claims Processing Procedures When Required Face-to-Face Encounters Do Not Occur Timely

October 7, 2011

January 9, 2012

• Missed or late face –to-face encounter • https://www.cms.gov/transmittals/downloads/

R2316CP.pdf

Change Request 7677 - New Hospice Condition Code for Out of Service Area Discharges

February 3, 2012

July 1. 2012

• Discontinuation for “code 42” for missed/ late face-to-face encounter

• https://www.cms.gov/transmittals/downloads/R2410CP.pdf

Sec. §418.22 - Certification of terminal illness (a) Timing of certification—

(1) General rule. The hospice must obtain written certification of terminal illness for each of the periods listed in § 418.21, even if a single election continues in effect for an unlimited number of periods, as provided in § 418.24(c).

(2) Basic requirement. Except as provided in paragraph (a)(3) of this section, the hospice must obtain the written certification before it submits a claim for payment.

(3) Exceptions. (i) If the hospice cannot obtain the written certification within 2 calendar days,

after a period begins, it must obtain an oral certification within 2 calendar days and the written certification before it submits a claim for payment.

(ii) Certifications may be completed no more than 15 calendar days prior to the effective date of election.

(iii) Recertifications may be completed no more than 15 calendar days prior to the start of the subsequent benefit period.

(4) Face-to-face encounter. As of January 1, 2011, a hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient whose total stay across all hospices is anticipated to reach the 3rd benefit period. The face-to-face encounter must occur prior to, but no more than 30 days prior to, the 3rd benefit period recertification, and every benefit period reconciliation thereafter, to gather clinical findings to determine continued eligibility for hospice care.

(b) Content of certification.

Page 9 of 10 © National Hospice and Palliative Care Organization, Revised December 2013

Certification will be based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness. The certification must conform to the following requirements:

(1) The certification must specify that the individual’s prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course.

(2) Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification as set forth in paragraph (d)(2) of this section. Initially, the clinical information may be provided verbally, and must be documented in the medical record and included as part of the hospice’s eligibility assessment.

(3) The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms.

(i) If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician’s signature.

(ii) If the narrative exists as an addendum to the certification or recertification form, in addition to the physician’s signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum.

(iii) The narrative shall include a statement directly above the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient’s medical record or, if applicable, his or her examination of the patient.

(iv) The narrative must reflect the patient’s individual clinical circumstances and cannot contain check boxes or standard language used for all patients.

(v) The narrative associated with the 3rd benefit period recertification and every subsequent recertification must include an explanation of why the clinical findings of the face-to-face encounter support a life expectancy of 6 months or less.

(4) The physician or nurse practitioner who performs the face-to-face encounter with the patient described in (a) (4) of this section must attest in writing that he or she had a face-to-face encounter with the patient, including the date of that visit. The attestation of the nurse practitioner or a non-certifying hospice physician shall state that the clinical findings of that visit were provided to the certifying physician for use in determining continued eligibility for hospice care.

(5) All certifications and recertifications must be signed and dated by the physician(s), and must include the benefit period dates to which the certification or recertification applies.

(c) Sources of certification.

(1) For the initial 90-day period, the hospice must obtain written certification statements (and oral certification statements if required under paragraph (a)(3) of this section) from--

(i) The medical director of the hospice or the physician member of the hospice interdisciplinary group; and

Page 10 of 10 © National Hospice and Palliative Care Organization, Revised December 2013

(ii) The individual's attending physician if the individual has an attending physician. The attending physician must meet the definition of physician specified in § 418.20 of this subchapter.

(2) For subsequent periods, the only requirement is certification by one of the physicians listed in paragraph (c)(1)(i) of this section.

[48 FR 56026, Dec. 16, 1983, as amended 70 FR 45144, August 4, 2005]

(d) Maintenance of records. Hospice staff must--

(1) Make an appropriate entry in the patient's medical record as soon as they receive an oral certification; and

(2) File written certifications in the medical record. [55 FR 50834, Dec. 11, 1990, as amended at 57 FR 36017, Aug. 12, 1992; 70 FR 70547, November 22, 2005 as amended 84 FR 39413, August 6, 2009, as amended 75 FR 70463, November 17, 2010, as amended July 29, 2011 in the FY2012 Final Hospice Wage Index Rule] Link to Federal Regulations: 42 CFR §418.22

http://www.gpo.gov/fdsys/pkg/CFR-2012-title42-vol3/pdf/CFR-2012-title42-vol3-part418-subpartB.pdf

References CMS. (2005, Jan 28). CR3686. Retrieved Dec 18, 2013, from Centers for Medicare and Medicaid Services: http://www.cms.hhs.gov/Transmittals/downloads/R458CP.pdf CMS. (2009, Apr 3). Medicare Claims Processing Manual-Chapter 11. Retrieved Dec 18, 2013, from Centers for Medicare and Medicaid Services: http://www.cms.hhs.gov/manuals/downloads/clm104c11.pdf CMS. (2005, Nov 22). Medicare Program; Hospice Care. Retrieved Dec 18, 2013, from Federal Register: http://www.cms.hhs.gov/QuarterlyProviderUpdates/downloads/CMS1022F.pdf CMS. (2004, Dec 03). Medicare Benefit Policy Manual, Chapter 9. Retrieved Dec 18, 2013, from Centers for Medicare and Medicaid Services: http://www.cms.hhs.gov/manuals/Downloads/bp102c09.pdf Federal Register, (2010, November 2) Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011; Changes in Certification Requirements for Home Health Agencies and Hospices, Retrieved Dec 18, 2013: http://www.gpo.gov/fdsys/pkg/FR-2010-11-17/pdf/2010-27778.pdf