2016 Hospice Workshop Series

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2016 Hospice Workshop Series Protecting Your Dollars Making Cents Out of Medicare Part I February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 2 Disclaimer The information
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2016 Hospice Workshop Series Protecting Your Dollars Making Cents Out of Medicare Part I February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 2 Disclaimer The information enclosed was current at the time it was presented. Medicare policy changes frequently; links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. Palmetto GBA employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This presentation is a general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. All Current Procedural Terminology (CPT) only copyright 2015 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable Federal Acquisition Regulation/ Defense Federal Acquisition Regulation (FARS/DFARS) Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 3 1 Agenda Data Review Aggregate Length of Stay (ALOS) Revenue Code Billing by State Non-Cancer Length of Stay (NCLOS) Going Beyond Diagnosis TM Medical Necessity: Parkinson s Disease Comprehensive Error Rate Testing (CERT) Errors Pain Documentation Activities of Daily Living (ADL) Assessment Continuous Home Care (CHC) February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 4 Objectives Discuss Palmetto GBA hospice data and its significance Discuss how to use Going Beyond Diagnosis to facilitate the assessment and documentation process Discuss medical necessity documentation for Parkinson s Disease Discuss pain documentation and assessment of Activities of Daily Living Discuss data related to levels of care and demonstrate techniques for CHC February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 5 Data Review February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 6 2 Total Hospice Agencies by Year 2014, NHPCO National Data Set and/or NHPCO Member Database February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 7 Medicare-Certified Hospices by State 1st Quarter 2015, Centers for Medicare and Medicaid Services (CMS) Provider of Service File (POS) February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 8 Number of Providers JM 1911 total hospice providers 1722 freestanding (81X) 189 hospital based (82X) 86 providers outside of the 16 states February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 9 3 Total Hospice Patients Served by Year 2014, NHPCO National Data Set and/or NHPCO Member Database February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 10 Number of Beneficiaries JM Total beneficiaries: 426, ,548 (81X) 35,014 (82X) 32,787 outside of the 16 states February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 11 Length of Service by Year 2014, NHPCO National Data Set and/or NHPCO Member Database February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 12 4 Proportion of Patients by Length of Service in , NHPCO National Data Set and/or NHPCO Member Database February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 13 Aggregate Length of Stay (LOS) State Mean LOS Mean Cancer LOS Mean Noncancer LOS Tennessee Jurisdiction February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 14 Aggregate LOS State % SSI % % Alzheimer's % Mental Other Heart Tennessee Jurisdiction February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 15 5 Aggregate LOS State % Beneficiaries with Multiple Providers % Beneficiaries with Discharge Disbursement per Beneficiary Tennessee ,890 Jurisdiction ,439 February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 16 Percentage of Patient Care Days by Level of Care 2014, NHPCO National Data Set and/or NHPCO Member Database February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 17 Hospice Level of Care (LOC) LOC All Episodes Patient Home Nursing Home Assisted Living RHC 86.45% 99.39% 92.81% 99.38% CHC 6.18% 6.82% 5.14% 10.69% GIP 22.27% 0.56% 6.88% 0.40% IRC 3.40% 0.61% 6.52% 0.12% Medicare Hospice Payment Reform: Hospice Study Technical Report HHSM I February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 18 6 Revenue Code 651 Routine Bill Type State Provider Count Beneficiary Count Covered Units per Beneficiary 81x TN 50 14, x 8 1, February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 19 Revenue Code 652 CHC Bill Type State Provider Count Beneficiary Count Covered Units per Beneficiary 81x TN x February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 20 Comparative Billing Report Findings July 1, 2014 and June 30, 2015 February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 21 7 Comparative Billing Report Findings CBR Data Criteria Jurisdiction Length of Stay 24.4 Units per Beneficiary 96 Percent of CHC claims 0.8 February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 22 Revenue Code 655 Respite Bill Type State Provider Count Beneficiary Count Covered Units per Beneficiary 81x TN x February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 23 Revenue Code 656 GIP Bill Type State Provider Count Beneficiary Count Covered Units per Beneficiary 81x TN 35 2, x February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 24 8 GIP Charges State GIP Charges Total Charges Percent of GIP to Total Claims TN 17,724, ,928, February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 25 GIP Charges State GIP HCN count Total HICN Count Percent of GIP HICN to Total HICN TN 17,724, ,928, February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 26 TN GIP statistics Location of Service Percent of GIP Total Charges LOS # Beneficiaries % of GIP of Total HICNs SNF Hospital , Hospice , LTCH PSYCH NOS February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 27 9 Disbursement TN Bill Type Provider Disbursement Provider Count Provider Disbursement Beneficiary Count per Provider 81x Hospice 146,132,1477 (Freestanding) 50 2,922,643 16,643 82x Hospice (Hospital) 6,882, ,317 1,321 February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 28 Disbursement TN Bill Type Provider Disbursement Billed Charges Claim Count per Beneficiary 81x Hospice (Freestanding) 8, ,892,004 44,464 82x Hospice (Hospital) 4,210 15,188,522 2,459 February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 29 Percentage of Hospice Admissions by Primary Diagnosis 2014, NHPCO National Data Set and/or NHPCO Member Database February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 30 10 Non-Cancer Length of Stay (NCLOS) Rates NCLOS Rates are calculated using the following formula: Number of non-cancer beneficiaries with LOS 210 Total number of non-cancer beneficiaries The units are per 100 beneficiaries Values range from 0 to 1 February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 31 NCLOS Rates STATE_NAME # of Providers Total LOS Beneficiaries LOS 210 NCLOS ALABAMA ,380, , , ARKANSAS , , , FLORIDA ,065, , , GEORGIA ,258, , , ILLINOIS ,259, , , INDIANA ,497, , , KENTUCKY , , LOUISIANA ,673, , , MISSISSIPPI ,159, , , NEW MEXICO , , NORTH CAROLINA ,453, , , OHIO ,108, , , OKLAHOMA ,464, , , SOUTH CAROLINA ,156, , , TENNESSEE ,591, , , TEXAS ,541, , , February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 32 Regions February 2012 Palmetto GBA Jurisdiction C Home Health and Hospice Contractor 33 11 All Providers Policy Average Length of Stay (In Days) Policy Specific NCLOS Rate Certain Conditions Originating in the Perinatal Period Complications of Pregnancy, Childbirth, and the Puerperium Congenital Anomalies Diseases of the Blood and Blood-Forming Organs Diseases of the Circulatory System Diseases of the Digestive System Diseases of the Genitourinary System Diseases of the Musculoskeletal System and Connective Tissue Diseases of the Nervous System and Sense Organs Diseases of the Respiratory System Diseases of the Skin and Subcutaneous Tissue Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders Infectious and Parasitic Diseases Injury and Poisoning Mental, Behavioral and Neurodevelopmental Disorders Symptoms, Signs, and Ill-Defined Conditions Total (All Conditions) February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 34 NCLOS By region Southeast Region Southeast Providers Policy Average Length of Stay (In Days) Policy Specific NCLOS Rate Certain Conditions Originating in the Perinatal Period Complications of Pregnancy, Childbirth, and the Puerperium Congenital Anomalies Diseases of the Blood and Blood-Forming Organs Diseases of the Circulatory System Diseases of the Digestive System Diseases of the Genitourinary System Diseases of the Musculoskeletal System and Connective Tissue Diseases of the Nervous System and Sense Organs Diseases of the Respiratory System Diseases of the Skin and Subcutaneous Tissue Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders Infectious and Parasitic Diseases Injury and Poisoning Mental, Behavioral and Neurodevelopmental Disorders Symptoms, Signs, and Ill-Defined Conditions Total (All Conditions) February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 36 12 Number of Providers Number of Providers Number of Providers 10/20/2016 Diseases of the Circulatory System NCLOS Rates 37 Diseases of the Respiratory System NCLOS Rates 38 Symptoms, Signs, and Ill-Defined Conditions NCLOS Rates 39 13 NCLOS Rate Circulatory Tenn NCLOS Rate Nervous System Tenn NCLOS Rate Respiratory Tenn 14 NCLOS Rate SSI Tenn 0 NCLOS Rate by Q Code All conditions Tenn MR Top Denials 81X Total Denied Claims = 323 Denial Code Denial Code Description Count of Claims Denied by Bill Type Percent of Claims Denied to Total Claims Denied by Bill Type 5CF36 Not Hospice Appropriate CFNP No Plan of Care Submitted Auto Denial - Requested Records not Submitted CNOE No Valid Election Statement Submitted LCD Denial - no medical necessity CF01 5CFH9 General Inpatient Services Not Reasonable and Necessary _ Beneficiary Liable Physician Narrative Statement Not Present or Not Valid CFH6 Initial Certification Not Timely CFH2 No Certification Present CFTF Face to Face Encounter Requirements Not Met February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 45 15 MR Top Denials 82X Total Denied Claims = 13 Denial Code Denial Code Description Percent of Claims Denied to Count of Claims Total Claims Denied by Bill Denied by Bill Type Type 5CFNP No Plan of Care Submitted Auto Denial - Requested Records not Submitted CF36 Not Hospice Appropriate CFH6 Initial Certification Not Timely CFH2 No Certification Present CNOE No Valid Election Statement Submitted February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 46 January March 2015 TN Denial Claims Jan-Mar Denied Charges Submitted Charges Jan-Mar Code Denial Description 2015 Jan-Mar none 4 $0.00 $10, February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 47 April June 2015 TN Denied Submitted Denial Code Denial Description Claims Apr-Jun 2015 Charges Apr-Jun 2015 Charges Apr-Jun 2015 none February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 48 16 July September 2015 TN Submitted Denial Claims Denied Charges Charges Code Denial Description Jul-Sep 2015 Jul-Sep 2015 Jul-Sep 2015 none 1 $0.00 $3, February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 49 October December 2015 TN Denial Claims Oct-Dec Denied Charges Submitted Charges Oct-Dec Code Denial Description 2015 Oct-Dec none 1 $0.00 $ February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 50 Going Beyond Diagnosis TM February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 51 17 How do I Tell My Story? February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 52 Something Was Missing Studies show that diagnosis alone does not predict: Service needs Length of hospitalization Level of care Functional outcomes February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 53 Reciprocal Determinism Reciprocal determinism is the theory set forth by psychologist Albert Bandura that a person's behavior both influences and is influenced by personal factors and the social environment. Bandura, A. (1986). Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall. February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 54 18 Human Ecology Approach Bronfenbrenner Urie. (1979). The Ecology of Human Development: Experiments by Nature and Design. Cambridge, MA: Harvard University Press. ISBN February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative 55 Contractor (MAC) Biopsychosocial (BPS) Model BPS model is an interdisciplinary model that assumes that health and wellness are caused by a complex interaction of biological, psychological, and sociocultural factors. This model was first explained by psychiatrist George L. Engel in Science journal in This model is based on the system perspective. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196: Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry 1980; 137: February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 56 World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations (UN) that is concerned with international public health. It was established on 7 April 1948, headquartered in Geneva, Switzerland. February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 57 19 Framework February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 58 Parkinson s Disease February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 59 Case Study CP is an 82-year-old female with a terminal diagnosis of Parkinson s Disease. Comorbidities identified in the medical record include: Shy-Drager Syndrome COPD with pulmonary hypertension Atrial Fibrillation Aortic Stenosis with past history of Coronary Heart Disease S/P MI Osteoarthritis Secondary conditions: Depression Malnutrition February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 60 20 Case Study The aortic stenosis is described as mild moderate; associated with bilateral atrial enlargement and severe tricuspid regurgitation. CP s mobility is described as being limited secondary to: Increasing tremors Increasing shortness of breath Increasing weakness She is restricted to the bed or couch and requires maximum assistance - even with a walker. Records document that, in fact, CP requires maximum assistance with all Activities of Daily Living (ADLs). February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 61 Case Study History obtained from hospital records documents that one year prior to hospice admission CP was hospitalized for syncope and left hip fracture. At that time she was noted to be alert and oriented x 2, but no further information was documented regarding her past cognitive status. Following rehabilitation she was discharged using a walker for mobility and required minimal assistance with ADLs. CP complains of occasional knee pain related to osteoarthritis. February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 62 Case Study CP s son reports that over the past year his mother s weight has decreased from 187 lbs to 102 lbs. CP is noted to be 5 2 tall (BMI = 18.6 kg/m2). She is afebrile with a documented radial pulse rate varying from beats per minute, respiratory rate of breaths per minute and BP between 80/60 130/80. She is maintained on Florinef for hypotension. History from a recent clinic visit documented that CP had an increased cardiac silhouette and mild vascular prominence on chest x-ray. February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 63 21 Case Study CP s appetite is described as fair to poor and she is noted to eat very little. She has temporal wasting and is is not very talkative. CP is maintained on a soft, puree diet supplemented by Ensure TID. She is now reported to be alert and oriented x 0. February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 64 ICD-10-CM Code G20 G23.2 Parkinson s Disease Paralysis agitans Description Other degenerative diseases of the basal ganglia Striatonigral degeneration (Shy-Drager syndrome) F32.9 Depressive disorder, not otherwise specified I25.11 Coronary atherosclerosis I48.91 Atrial Fibrillation J44.9 Chronic pulmonary heart disease (Obstructive chronic bronchitis ) I27.2 Pulmonary hypertension, secondary I35.0 Nonrheumatic aortic (valve) stenosis I36.1 Nonrheumatic tricuspid (valve) insufficiency I25.2 Old myocardial infarction I51.7 Cardiomegaly (bilateral atrial enlargement) M17.10 Unilateral primary osteoarthritis, unspecified knee R63.4 Abnormal weight loss Z68.1 Body mass index (BMI) 19 or less, adult February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 65 What is Parkinson s Disease? Parkinson's Disease is a chronic and progressive movement disorder, meaning that symptoms continue and worsen over time. Parkinson s Disease Foundation February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 66 22 What is Parkinson s Disease? Parkinson s Disease involves the malfunction and death of vital nerve cells in the brain, called neurons. Parkinson s Disease primarily affects neurons in the area of the brain called the substantia nigra. Some of these dying neurons produce dopamine, a chemical that sends messages to the part of the brain that controls movement and coordination. As Parkinson s Disease progresses, the amount of dopamine produced in the brain decreases, leaving a person unable to control movement normally. Parkinson s Disease Foundation February 2016 Palmetto GBA - A CMS-Contracted Medicare Administrative Contractor (MAC) 67 What is Parkinson s Disease? Parkinson s Disease develops as cells are destroyed in certain parts of the brain stem, particularly the cresce
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