NHPCO Talking Points for FY2014 Proposed Wage Index Rule
Details of Comment Letter
Due Date: June 28 2013
Adddress:
Marilyn Tavenner, Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS–1449–P
P.O. Box 8010
Baltimore, MD 21244–8010
How to File Comments:
The easiest way to file comments on this proposed rule is to use the website www.regulations.gov. You can file comments electronically as late as the day they are due and have them considered by the CMS staff who will be writing the final rule.
Here are the steps for finding the proposed rule and filing comments:
1. Search for “hospice” in search box
2. When the proposed rule CMS-1449-P is identified in the list, click on the blue “Comment Now” box.
3. You can make comments in the text box alone or attach an official letter from your agency.
4. Make sure that your letter is received no later than 11:59 pm on June 28.
Sections of Comment Letter:
Note: These talking points follow the outline of the CMS proposed rule and the basic outline should be used in writing comments.
A. Diagnosis Reporting on Hospice Claims
1. ICD-9-CM Coding Guidelines
From the proposed rule: We clarified in our July 27, 2012 FY 2013 Hospice Wage Index notice (77 FR 44247 through 44248) that all providers should code and report the principal diagnosis as well as all coexisting and additional diagnoses related to the terminal condition or related conditions to more fully describe the Medicare patients they are treating.
Comments: Any comments on coding, using the coding guidelines, comments on the role of the hospice physician and the use of professional coders in hospice.
From the proposed rule: We also discussed related versus unrelated diagnosis reporting on claims and clarified that ‘‘all of a patient’s coexisting or additional diagnoses’’ related to the terminal illness or related conditions should be reported on the hospice claims… For beneficiaries eligible for the Medicare hospice benefit, access to hospice care or the continuation of hospice care should not be affected or limited by the following ICD–9–CM coding guidelines for diagnosis reporting on claims.
Questions to answer in your comments:
1. Does your hospice report multiple diagnoses on the claim form?
2. How does your hospice determine whether a condition is related to the terminal illness? Describe the process and comment on the differences between the patient 3-6 months before death and closer to death.
3. Comment on coexisting or additional diagnoses and the challenge of determining relatedness.
4. Note the vital role of the hospice physician as the key in determining relatedness – and how that role must be central to the ongoing attention to pain and other symptoms, as well as consideration for all conditions that the patient may be facing.
5. Provide a case example where the patient’s long standing condition would be or would not be related to the terminal illness.
6. Describe the difficulty in determining relatedness in some patients.
2. Use of Nonspecific, Symptom Diagnoses
a. From the proposed rule (comment on the use of debility and adult failure to thrive): “Adult Failure to Thrive” is often used interchangeably with “Debility” as a primary hospice diagnosis. Despite the specificity of ICD–9–CM Coding Guidelines, it is unclear as to why these two diagnoses are often used interchangeably. A reported principal hospice diagnosis in the nonspecific ICD–9–CM category, “Symptoms, Signs, and Ill-Defined Conditions”, such as “debility” or “adult failure to thrive,” does not encompass the comprehensive, holistic nature of the assessment and care to be provided under the Medicare hospice benefit.
Questions to answer in your comments:
1. Describe the role of the hospice physician in determining diagnoses and documenting in the medical record.
2. Write case examples of when either debility or adult failure to thrive would be an appropriate diagnosis. Here is an example of such a case:
Case example of patient with Adult Failure to Thrive, written by a hospice physician:
JR was the oldest patient I ever cared for. She had history of remote colon cancer (surgically cured when she was 95), which is when she entered the nursing home under my care. After recovering from her surgery, her medical conditions consisted of osteoarthritis (moderate) and mild cognitive impairment. Several months before her 107th birthday, she began to lose weight and she became functionally more debilitated. She stated that her arthritis was no worse, and no other new problems were identified. She declined any major diagnostic evaluations. Laboratory showed very mild anemia, but there was no evidence of recurrence of her cancer. Efforts to improve nutrition and function were unsuccessful. Over the next few months, her BMI fell to 17 and her PPS declined to 40%. There was no more specific diagnosis identified that Adult Failure to Thrive, the Palmetto LCD criteria for which she easily met. She was admitted to hospice with this diagnosis and died ten weeks later after a progressive course, during which time no other diagnoses were ever identified. Adult Failure to Thrive was the diagnosis entered on her death certificate.
b. From the proposed rule (comment on comprehensive assessment): If a nonspecific, ill-defined diagnosis is reported as the principal hospice diagnosis, a comprehensive, individualized patient-centered plan of care, as required, may be difficult to accurately develop and implement, and, as a result, the hospice beneficiary may not receive the full benefit of hospice services.
Questions to answer in your comments:
1. Comment on the “comprehensive, individualized patient-centered plan of care, as required, may be difficult to accurately develop and implement….” sentence in the proposed rule.
a. How does the hospice physician determine a diagnosis?
b. How does the comprehensive assessment fit into this process?
c. Describe your recent efforts to identify other primary diagnoses, in preparation for these changes.
d. How would your hospice choose debility or adult failure to thrive, especially after evaluating the patient holistically?
2. In cases where there are multiple co-morbid conditions, how is the plan of care developed so that the hospice beneficiary receives the “full benefit of hospice services.”
3. Add case studies that describe how the diagnosis is determined and how the plan of care is developed.
c. From the proposed rule: When reported as a principal diagnosis, these would be considered questionable encounters for hospice care, and the claim would be returned to the provider for a more definitive principal diagnosis. ‘‘Debility’’ and ‘‘adult failure to thrive’’ could be listed on the hospice claim as other, additional, or coexisting diagnoses. We believe that the private sector requires that ICD–9–CM coding guidelines be followed; this includes not allowing ‘‘debility’’ and ‘‘adult failure to thrive’’ as principal diagnoses on private sector hospice claims.
Questions and comments to address:
1. When will the RTP direction be given to Medicare Administrative Contractors?
2. How will the legitimate use of debility or adult failure to thrive be distinguished from claims where another diagnosis can be used?
3. Comment on your hospice’s experience with private sector use of these diagnoses and any other ICD-9-CM coding guidelines required for claims submission.
3. Use of ‘‘Mental, Behavioral and Neurodevelopmental Disorders’’ ICD–9– CM Codes
Any comments on coding for Alzheimer’s and other dementia patients.
4. Guidance on Coding of Principal and Other, Additional, and/or Co-existing Diagnoses
From the proposed rule: Based on the ICD–9–CM coding guidelines, the circumstances of an inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as ‘‘that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.’’
Questions to answer in comments:
Note: A professional coder could be an asset in providing comments on this section.
1. Give examples of when the diagnosis for the hospital admission would be the same or different for the hospice admission.
2. Reference the role of the hospice physician in determining diagnosis for the purposes of determining eligibility for the Medicare hospice benefit.
3. Note that the hospital’s admitting diagnosis may or may not be known when the patient is referred to hospice. Cite your hospice’s experience with admissions.
4. Use case examples to identify issues with the coding of principal and other diagnoses.
B. Proposed Update to the Hospice Quality Reporting Program
1. Quality Measures for Hospice Quality Reporting Program and Data Submission Requirements for Payment Year FY2014
No comments.
2. Quality Measures for Hospice Quality Reporting Program and Data Submission Requirements for FY2015 and Beyond
From the proposed rule: We solicit comment on the removal of the checklist and data source questions from the structural measure, and the removal of the NQF #0209 measure. We also solicit comment on the alternative proposal of maintaining NQF #0209 until another pain outcome measure is available.
Guide for comments:
Provide your agency’s comments on the elimination of current measures (payment year FY 2015)
a. QAPI Structural measure
b. NQF 0209 – which is a better option?
§ Discontinue after current data collection
§ Maintain until another pain outcome measure is available
3. Quality Measures for Hospice Quality Reporting Program for Payment Year FY2016 and Beyond
From the proposed rule: We contracted with RTI International to support the development of the Hospice Item Set (HIS) for use as part of the HQRP. In developing the HIS, RTI focused on the NQF endorsed measures that had evidence of use and/or testing with hospice providers.
We have included data items that support the following NQF endorsed measures for hospice:
• NQF #1617 Patients treated with an opioid who are given a bowel regimen
• NQF #1634 Pain screening
• NQF #1637 Pain assessment
• NQF #1638 Dyspnea treatment
• NQF #1639 Dyspnea screening
• NQF #1641 Treatment preferences
• NQF #1647 Beliefs/Values addressed (if desired by the patient)
Guide for Comments:
Hospice Item Set (HIS)
a. Measures
· Problems/considerations with specific measures
b. Implementation
· Problems/considerations related to implementation
· Rolling submission
· Timing (start July, 2014)
4. Public Availability of Data Submitted
From the proposed rule: The Affordable Care Act requires that reporting be made public on a CMS Web site and that providers have an opportunity to review their data prior to public reporting. CMS will develop the infrastructure for public reporting, and provide hospices an opportunity to review their data. In light of all the steps required prior to data being publicly reported, we anticipate that public reporting will not be implemented in FY 2016. Public reporting may occur during the FY 2018 Annual Payment Update (APU) year, allowing ample time for data analysis, review of measures’ appropriateness for use for public reporting, and allowing hospices the required time to review their own data prior to public reporting.
Guide for comments:
a. Measures (from HIS)
b. Timing (initiate in 2017/2018 APU year or later)
5. Proposed Adoption of CMS Hospice Experience of Care Survey for the FY2017 Payment Year
From proposed rule: The Hospice Experience of Care Survey captures such topics as hospice provider communications with patients and family members, hospice provider care, and patient and family member characteristics. The survey would allow the informal caregiver (family member or friend) to provide an overall rating of the hospice care their patient received, and would ask if they would recommend “this hospice” to others.
Guide for comments:
a. Timing of implementation (1st quarter 2015) and six months after the implementation of the HIS data collection system
b. Participation affects payment determination for 2017
c. Exemption (fewer than 50 deaths in 2014)
d. Concerns about surveys being available in other languages, in addition to Spanish
C. FY2014 Hospice Rate Update
No comments required.
D. Update on Hospice Payment Reform and Data Collection
1. Update on Reform Options
a. Rebasing the Routine Home Care Rate
· Cost report data being used as the basis for rebasing has never been audited.
· A standard inflation factor has been applied for all non-staff components. The rise in the cost of drugs and supplies has exceeded the standard inflation factor.
· Not all disciplines are reflected in the 9 components for the routine home care rate.
· Your hospice’s CFO may have comments that are applicable to this section of the proposed rule.
b. Site of Service Adjustment for Hospice Patients in Nursing Facilities
· More data is needed to determine the prevalence of high numbers of hospice patients in one nursing home.
· Cite your hospice’s experience with caring for nursing home residents and how many patients are in one nursing home.
· Cite your hospice’s experience with the acuity of nursing home residents receiving hospice care and the need for hospice staff.
· Other cost and time considerations for hospice patients in nursing homes:
o Coordination of care time increases in the facility and is not accounted for.
o Attendance at care conferences, time and disciplines are not captured and is not accounted for.
o Nursing home room and board is 95% of the rate. The hospice makes up the other 5% of the rate for services purchased from the nursing home. The 5% is not accounted for.
o Staffing with aide services: Hospice aides are often called in because they are much more adept at dealing with situations at the end of life.
One Final Note:
In these comments, use your hospice’s experience with patients, use case examples and involve your hospice physicians, medical director, quality staff, certified coder, and CFO in writing comments about the various sections of this proposed rule. It is complex and comments are needed in a variety of areas.
Thank you in advance for submitting comments.
7 | NHPCO Talking Points on CMS FY2014 Proposed Wage Index Rule