Welcome to the How to Document the Six-Month Terminal Prognosis and Avoid Claim Denials eLearning Module. Medicare claim denials can result in significant costs in both revenue and time for hospice providers. Reasons Medicare claims are denied include services that did not meet medical necessity, frequency limitations, and missing and even basic coding mistakes.
But for hospice, the number one reason is inadequate medical record documentation to support a terminal prognosis of six months or less, denial code 5PM01. In fact, between July and September 2022, this accounted for 59% of all the denials. The good news is that you can easily avoid claim denials like this with proper documentation.
In this module, you will learn how to provide proper documentation for hospice claims to avoid claims denials. You will get tips to avoid common hospice certification of terminal illness prognosis documentation errors. Upon completion of this eLearning module, you will describe the Medicare requirements for a terminal illness prognosis, explain local coverage determination guidance on hospice determining terminal status, recognize the importance of proper medical record documentation supporting hospice terminal prognosis to reduce claims denials.
This module includes quiz questions to reinforce the information being presented. The problem, the top reason Medicare denies hospice claims centers on insufficient documentation, which is projected to result in $2.9 billion in improper payments. Medical reviewers evaluate all hospice claims to ensure documentation supports a terminal illness prognosis, defined as the expectation that the patient will only live for six months or less.
The medical reviewer will never see this patient, so the care team must present a visual picture of the patient, their condition, and symptoms to support the terminal illness prognosis. Some top gaps in documenting this include, claims go through review and are denied because they aren't meeting the local coverage determination, LCD, status clinically, physicians are not charting the patient's decline, nurses aren't supporting the documentation by the physician, a palliative performance scale is used, but documentation doesn't support the scale's rating.
Terminal illness prognosis requirements and certification of terminal illness. To be eligible for hospice, a patient must have a terminal illness prognosis of six months or less, according to the Medicare hospice requirements. This is true at the time of admission and must be maintained for the entire time that the patient is receiving hospice services.
Further, certification of terminal illness must also occur for the patient to receive or continue to receive hospice services. Let's start with a quick review of each of these terms, terminal illness prognosis and certification of terminal illness. Defining terminal illness prognosis.
A terminal illness prognosis is a life expectancy of six months or less if the terminal illness in an individual runs its normal course. Only care provided by or under arrangements made by a Medicare certified hospice is covered under the Medicare Hospice benefit.
The hospice admits a patient only on the recommendation of the medical director in consultation with or with input from the patient's attending physician if they have one. Documentation to support a terminal illness prognosis is often incomplete and contributes to claims denials.
The patient's care team should document specific measures to show the patient's condition is declining. These measures directly correlate to the limited coverage determination guidelines issued by CMS. We will discuss these in detail in the following sections. Certification of terminal illness for hospice benefits should be based on the clinical judgment of the hospice medical director or physician member of the interdisciplinary group, IDG, and the individual's attending physician if he or she has one regarding the normal course of the individual's illness.
In reaching a decision to certify that the patient is terminally ill, the hospice medical director must consider at least the following information: diagnosis of the terminal condition of the patient, other health conditions, whether related or unrelated to the terminal condition, current clinically relevant information supporting all diagnoses.
No one other than a medical doctor or doctor of osteopathy can certify or re-certify a terminal illness. We will discuss certification of terminal illness later in this module as well. True or false, a terminal illness prognosis is a life expectancy of 12 months or less if the terminal illness in an individual runs its normal course.
Local coverage determination. As previously noted, local coverage determinations are policies that describe guidelines for determining a patient's status. In the case of hospice, LCDs describe guidance on determining whether a patient is considered to have a terminal illness prognosis. MACs are Medicare administrative contractors that review and process Medicare claims.
They use LCDs to identify any Medicare beneficiary whose current clinical status and anticipated progression of disease is more likely than not to result in a life expectancy of six months or less. As stated earlier, the top reason for Medicare hospice medical review denial, reason 5PM01 six month terminal prognosis not supported is inadequate information and documentation to support a terminal prognosis of six months or less.
Let's find out how to avoid this by first learning about the LCD guidance on determining terminal prognosis. Please choose the single best answer. What is the top Medicare hospice medical review denial reason? A, incorrect coding for hospice services for patient with terminal prognosis of six months or less.
B, inadequate medical record documentation to support a terminal prognosis of six months or less. C, incorrect designation of the hospice medical director. D, none of the above. The LCD consists of three parts and disease specific guidelines. Part one centers on showing decline in clinical status.
Part two focuses on non-disease specific guidelines relating to a patient's functional limitations. Part two is used in conjunction with the disease specific guidelines. Part two cannot be used alone to predict a terminal illness prognosis. Part three discusses comorbidities that may be helpful in predicting and documenting a six-month prognosis.
The disease-specific guidelines used in conjunction with part two provide guidance on how to document progression of specific diseases such as cancer, dementia, and HIV disease to name a few. Determining terminal status using the LCD. So what are the specific indications that should be documented by a physician or other care team member to clearly support the terminal prognosis and avoid a claim denial under 5PM01?
Let's take a closer look at each part of the LCD guidelines to find out. Part one, decline in clinical status. Patients will be considered to have a life expectancy of six months or less if there is documented evidence of decline in clinical status based on part one of the LCD guidelines, decline in clinical status.
Since determination of decline presumes assessment of the patient's status over time, it is essential that both baseline and follow-up determinations be reported where appropriate. Baseline data may be established on admission to hospice or by using existing information from records. There are six clinical variables listed in LCD part one, which we'll describe momentarily.
Other clinical variables not on this list may support a six month or less life expectancy. These should be documented in the clinical record. The clinical status guidelines are listed in order of their likelihood to predict poor survival, the most predictive first and the least predictive last.
No specific number of variables must be met, but fewer of those listed first, more predictive, and more of those listed last, least predictive, would be expected to predict longevity of six months or less. Progression of a disease. The first clinical variable to consider is the progression of a disease.
You'll want to watch out for and document four items that are indicative of decline. You'll look for worsening clinical status, symptoms, signs, and laboratory tests. We'll get into more detail about what to look for and document next. Decline in KPS or PPS.
The remainder of the guidelines include decline in Karnofsky performance status, KPS, which is a simple subjective method to assess a patient's performance of activities of daily living or a palliative performance score, PPS, from less than 70% due to progression of disease.
Increasing ER visits, increasing emergency room visits, hospitalizations, or physician's visits related to hospice primary diagnosis. FAST, progressive decline in functional assessment staging tests, FAST, for dementia from less than or equal to 7A on the FAST. ADL, progression to dependence on assistance with additional activities of daily living.
Ulcers. And finally progressive stage three, four pressure ulcers in spite of optimal care. Since determination of decline presumes assessment of the patient's status over time, it is essential that both baseline and follow-up determinations be made and reported where appropriate. Baseline data may be established on admission to hospice or by using existing information from records.
Other clinical variables not on this list may support a six-month or less life expectancy, such as a record that shows a trajectory of decline and increasing ER visits or hospitalizations. These should be documented in the clinical record. Which of these items should be documented to show the progression of disease?
Which of the following palliative care screening tools are included in the documentation of the decline in clinical status guidelines? Part two, non-disease-specific baseline guidelines. In part two, non-disease-specific baseline guidelines, both of the following conditions must be met. One, you must record that the patient's physiologic impairment of function status as demonstrated by Karnofsky performance status or palliative performance score is less than 70%.
Two, the patient must depend on assistance for two or more activities of daily living, including feeding, ambulation, continence, transfer, bathing, and dressing. Disease-specific guidelines can be used in conjunction with the non-disease-specific guidelines. We'll talk about those a little later in this module.
When the word "Should" is used in disease-specific guidelines, it means the guidelines will be strongly considered when making coverage determination during medical review. Part three, comorbidities. Next, we'll discuss part three, comorbidities that can be used to document decline. These comorbidities include COPD, congestive heart failure, ischemic heart disease, diabetes mellitus, neurological disease, including CVA, ALS, MS, and Parkinson's, renal failure, liver disease, neoplasia, AIDS, and dementia.
Even though they may not be the primary reason for terminal illness, the presence of these comorbidities, the severity of which is likely to contribute to a life expectancy of six months or less should be documented for medical reviewers. A note on limitations.
Patient records that do not meet the LCD guidelines when undergoing medical review may be denied coverage unless other clinical circumstances reasonably predictive of a life expectancy of six months or less are provided. The condition of some patients receiving hospice care may stabilize or improve during or due to that care, with the expectation that the stabilization or improvement will not be brief and temporary.
In such circumstances, if the patient's condition changes such that he or she no longer has a prognosis of life expectancy of six months or less and that improvement can be expected to continue outside the hospice setting, then that patient should be discharged from hospice.
On the other hand, patients in the terminal stage of their illness who originally qualify for the Medicare hospice benefit, but stabilize or improve while receiving hospice care, yet have a reasonable expectation of continued decline for a life expectancy of less than six months, remain eligible for hospice care.
Disease-specific guidelines. The disease-specific guidelines should be used in combination with the non-disease-specific baseline guidelines described in part two. For instance, let's use dementia due to Alzheimer's disease as an example. Patients will only be considered to be in the terminal stage of dementia with a life expectancy of six months or less if they meet the criteria as seen here, including stage seven or beyond according to the functional assessment staging test, the patient being unable to ambulate, dress, or bathe without assistance, urinary and fecal incontinence, and no consistent meaningful verbal communication.
In addition, patients with dementia due to Alzheimer's disease need to have had the following within the past 12 months: aspiration pneumonia, pyelonephritis or other upper urinary tract infection, septicemia, multiple stage three, four decubitus ulcers, fever, recurrent after antibiotics, and the inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months, or serum albumin less than 2.5.
The full list of disease-specific guidelines is included in the LCD under general information. Documenting six-month terminal prognosis. Now that we've discussed how hospice coverage is determined, let's talk about how to properly document terminal prognosis of six months or less. It may be your initial instinct as a healthcare provider to document what you've been doing to help the patient improve their condition.
However, in situations where a patient is terminally ill and in hospice, even the best care will likely not help the patient improve. To avoid claims denials, it's critical to accurately paint a picture of the patient's health for the medical reviewer.
The medical review team will review every hospice claim and will never see the patient. So it's imperative that the care team provides clear documentation to support the terminal status. It may be helpful to remember this phrase as you're documenting. Why here?
Why now? Meaning, why are you here with this patient? And why now? What is going on that requires a member of the healthcare team at this time? There are specific items that can be documented to guide hospice providers and staff to improve the completeness and accuracy of documentation of Medicare covered hospice services.
Next, we're going to go over these items that, when documented, can help support the six-month terminal prognosis. And remember, including a good narrative in your notes while charting can go a long way in painting the picture for the medical reviewer.
Documentation to support the terminal prognosis at the time of hospice admission may include changes in or deterioration of a condition to initiate the hospice referral, diagnostic documentation to support terminal illness and an anticipated life expectancy of six months or less, and physician assessments and documentation.
You should also document a date of diagnosis, the course of the illness, the patient's desire for palliative curative care, and records that show a trajectory of decline. Documentation to support the terminal prognosis throughout the hospice election include changes in the patient's weight, worsening diagnostic lab results, changes in pain.
Examples of changes you can document include the type of pain, ache, throb, sharp, the location of the pain, upper lower, the frequency of the pain, constantly, hourly, daily, medication usage, including dosage, frequency, and effectiveness. You'll also want to document changes in responsiveness.
You can include things like alert, less responsive, unresponsive, skin integrity. Make note of whether the skin is fragile, intact, tears easily, or if there are broken wounds. You should also document any changes in the patient's dependence on assistance with activities of daily living.
Make note whether the patient can dress, bathe, and ambulate, and whether they can do these things assisted or unassisted. Also, document ambulation distance in feet or steps if applicable. Documentation should include changes in anthropomorphic measurements like abdominal girth measured in inches or centimeters and mid-arm or thigh circumference measurements also measured in inches or centimeters.
Changes in signs and symptoms should also be noted, including respiratory rate increases or decreases, dyspnea, oxygen flow rate documented by liters per minute, hyper or hypotension, radial or apical pulse noted as tachycardia, bradycardic, regular, irregular, edema, no details such as grade level one through four, pitting, non-pitting, and turgor.
Note whether it is slow or normal. You should also document incontinence and the frequency to which that occurs. Changes in strength or weakness should also be noted, along with changes in lucidity. You can note whether the patient is oriented or confused.
Changes in intake or output should be documented with details about the amounts documented in cups, liters, ounces, teaspoons, milligrams, milliliters, CCs, and frequency. Documentation is critical to the support of the terminal prognosis status. It's important to remember that your documentation should paint a picture of the patient's conditions and symptoms to support terminal prognosis.
This includes being objective and including quantifiable values or measures in your notes. For example, include pounds when documenting weight loss, include location on the pain scale, a four out of 10 when documenting increased pain. Include number of inches when documenting the MAC.
Documentation must paint a picture of the patient, their conditions and symptoms which support a life expectancy of six months or less. Avoid the use of vague statements such as "Disease progressing" or "Slow decline," as these statements do not include enough detail for a medical reviewer to certify that a patient's life expectancy is six months or less.
Congruency in documentation. Keep in mind that your documentation must be consistent across care team members and with whatever scoring scale you are using to evaluate your patient. Now, we are going to take a look at examples in which the documentation is incongruent with the patient status.
In this instance, the stated KPS score is 40, meaning the patient requires considerable assistance and medical care, and the palliative performance scale is also 40, meaning the patient is mostly bedridden, unable to perform most activities and requires assistance. However, the nursing documentation states that the patient is able to perform all of their activities of daily living independently.
The second example uses the functional assessment staging test to assess a patient resulting in a score of 7C, which is severe dementia and can no longer walk with a mental age of one year old. Yet the documentation states that the patient met chaplain at the door today and requested they walk outside during their visit, and the chaplain and patient walked around vegetable garden.
The last example classifies a patient using the New York Health Association classification of heart failure as classification four, meaning they are unable to carry on any physical activity without discomfort and have symptoms of heart failure at rest. Documentation states that the patient is comfortable at rest, can shower without assistance with brief rest, which is incongruent.
Certification of terminal illness, CTI. Now let's talk a little bit about certification of terminal illness. Please note, Medicare cannot make payments on claims with incorrect or missing dates, signatures, or identifying roles of the physicians, so accurate documentation on CTIs is critical.
Let's talk about some steps to help avoid the most common types of documentation errors. When is a CTI needed? For patients to receive hospice coverage under Medicare, physicians must complete CTI documentation at these intervals. Benefit period one, the first 90 days, benefit period two, the next 90 days, benefit periods three plus each subsequent 60-day period.
What should be included in the CTI? The CTI should include: statement of terminal illness, simple statement that the patient's life expectancy is six months or less if the terminal illness runs its normal course; clinical findings that support terminal illness, specific clinical findings, ergo patient diagnosis and prognosis, laboratory results, rapid decline in patient status to support a life expectancy of six months or less; hospice benefit period or periods specific from and through dates for each period of hospice care; narrative, synthesis of the patient's individual clinical circumstances that support a life expectancy of six months or less, and a statement attesting that the physician wrote the narrative based on their review of the patient's medical record or an examination; physician signature and date, legible physician signature and date directly below the narrative.
If illegible, type or print the name below the signature. Face-to-face encounter and attestation, face-to-face visit by a hospice physician or hospice nurse practitioner. What documentation do you need across benefit periods? It varies. Documentation requirements vary across benefit periods. This chart breaks down those differences.
More information can be found in this MLN matters article. Tips to avoid common hospice certification of terminal illness errors. Next, we'll go through a few tips to help avoid the most common mistakes when it comes to certification of terminal illness.
First, make sure the correct dates and signatures are included. Both the hospice medical director and attending physician, if applicable, need to sign the initial certification. Signatures need to be legible. If not, follow them with the printed or typed names. Ensure the physicians date their signatures.
Do not predate physician certification signatures. Second, be sure to include a physician narrative and attestation statement. Include a brief narrative explaining clinical findings that support a life expectancy of six months or less. The certification should give specific clinical findings, for example, signs, symptoms, laboratory testing, weights, et cetera.
Third, state the dates of certification. Clearly state the dates the certification period encompasses. For example, benefit period date, month/day/year, two, month/day/year. Fourth, complete the face-to-face encounter and attestation. A hospice physician or nurse practitioner must have a face-to-face encounter with each hospice beneficiary prior to the beginning of the beneficiary's third benefit period and prior to each subsequent benefit period.
Is this physician narrative statement complete? Further, notes about changes in pain and dyspnea and the patient's oxygen dependence and morphine cover changes in pain and signs and symptoms from the suggested documentation to support hospice services. Including a time period for the dyspnea and pain and frequency of morphine helps provide a clear picture of the patient's decline.
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