1. 2014 PPE Disclosure Statement
It is the policy of the Oregon Hospice Association to insure balance, independence, objectivity, and scientific rigor in all its educational programs. All faculty participating in any Oregon Hospice Association program is expected to disclose to the program audience any real or apparent affiliation(s) that may have a direct bearing on the subject matter of the continuing education program. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker from making a presentation. It is merely intended that any relationships should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts.
This presenter has no significant relationships with companies relevant to this presentation to disclose.

2. Up to the Minute Regulatory Update
Jennifer Kennedy, MA, BSN, CHC
National Hospice and Palliative Care Organization
Oregon Hospice Association Professional Practices Exchange Conference 2014

3. Recent regulatory updates
Effective August 1, 2014
Change in CMS QIO structure and contractors
Hospice providers update NOMNC forms
Effective August 4, 2014
Updates to Medicare Benefit Policy manual, Chapter 9 (multiple updates) – CR 8727
Effective October 1, 2014 – implementation of:
FY 2015 rates and wage index
NOE filing and penalty for non-compliance.
NOTR filing.

4. Recent regulatory updates
Effective October 1, 2014 – implementation of:
Attending physician on NOE and change form for patient choice of new attending physician.
Diagnosis reporting on hospice claims must adhere to ICD-9-CM coding conventions and guidelines.
Will implement certain edits from Medicare Code Editor (MCE).
Returned to Provider (RTP) for correction and resubmission prior to payment.
Part D plans must be compliant with CMS July 18, revised hospice medication coverage guidance.

5. What’s in the pipeline? Calendar year 2014 Calendar year 2015
Fall: CMS selects CAHPS vendors and trains them
Calendar year 2015
Hospice payment reform???
January: Hospice Experience of Care Survey (CAHPS) dry run
April: CAHPS implementation all providers
October:
ICD-10 implementation

6. Hospice surveys Medical review Hospice aggregate Cap
Impact Act
Hospice surveys
Medical review
Hospice aggregate Cap

7. IMPACT Act Stands for: Impacts post acute providers including:
Improving Medicare Post-Acute Care Transformation Act of 2014 (“IMPACT Act”)
Impacts post acute providers including:
home health agency
skilled nursing facility
inpatient rehabilitation facility
long-term care hospital

8. IMPACT Act
Requires post-acute providers to report standardized assessment data Provides congress with new payment models to consider for future reforms Protects beneficiary choice and access to care Shares quality data for discharge planning between providers Hospice provisions

9. Hospice Provisions in IMPACT bill
Three provisions:
Hospice surveys every 36 months
Implementation date: 6 months after enactment (when the Presidents the bill into law)
Surveys conducted by state survey agency or accrediting organization
In place for the next 10 years
Increased medical review for long lengths of stay
Technical correction to the Affordable Care Act
Intended for hospices who have a high percentage of patients with a length of stay >180 days
What is the “high percentage?”
CMS will set the number – in the 40-60% range
Implementation date: CMS can begin the process as soon as the bill is enacted (the date the President signs the bill into law)

10. Hospice Provisions in IMPACT bill
Hospice aggregate cap
Aligns the inflation increase for the aggregate cap and the hospice rate increase
Implementation date: FY2017 (Payment year beginning October 1, 2016)
Example of when cap amount and rates increase at same rate:
Example
Cap for year ending October 31, 2014
Marketbasket Increase
Example of Cap Amount for Coming Year
10/31/2014
$ ,725.79
1.70%
$ 27,180.13

11. CR 8877 NOE requirements Exceptions for NOE filing NOTR
Notice of election (NOE) and notice of termination or revocation (NOTR)
CR 8877
NOE requirements
Exceptions for NOE filing
NOTR

12. Change Request 8877
CMS issued CR 8877, Hospice Manual Update for Diagnosis Reporting and Filing Hospice Notice of Election (NOE) and Termination or Revocation of Election on August 22, 2014 with an effective date of October 1, 2014.
Resource for NHPCO members
Updates and Clarifications to the Hospice Policy Chapter of the Benefit Policy Manual -Compliance for Hospice Providers (September 2014)

13. Notice of Election (NOE)
§ Election of hospice care
(a) Filing an election statement
File the Notice of Election with MAC within 5 calendar days after effective date of election
Failure to submit:
Provider liable days: Medicare will not cover and pay for days of hospice care from the effective date of election to the date of filing of the NOE. Provider may not bill beneficiary
Exceptions for filing NOE late
Fires, floods, earthquakes or other unusual events
CMS or Medicare contractor system issue beyond the provider’s control

14. NOE Filing
File Notice of Election (NOE) as soon as possible after the election occurs
If filed ASAP:
Limits ability of other Part A, B and D providers to bill in error
Provides up to date information on face-to-face encounter
Identify current benefit period
Provide smooth transitions for sequential billing

15. NOE Filing – code 77
The hospice shall file the associated claim with occurrence span code 77 used to identify the non-covered, provider liable days and charges related to the level of care for these days shall be reported as non-covered, or the claim will be returned to the provider.
Even when claiming an exceptional circumstance as the cause of its late-filed NOE, the hospice shall file the associated claim with occurrence span code 77 used to identify the non-covered, provider liable days.

16. Bill type and filing method
Type of bill 8xA.
Entered via Direct Data Entry (DDE).

17. Notice of Termination/Revocation (NOTR)
§ Discharge from hospice care.
(e) Filing a Notice of Termination of Election.
When hospice election is ended due to discharge, the hospice must file a notice of termination/revocation of election with the MAC within 5 calendar days after the effective date of the discharge, unless it has already filed a final claim for that beneficiary.

18. Revocation § 418.28 Revoking the election of hospice care.
(d) When the hospice election is ended due to revocation, the hospice must file a notice of termination/revocation of election with its MAC within 5 calendar days after the effective date of the revocation, unless it has already filed a final claim for that beneficiary

19. Bill type and filing method
Type of bill 8xB.
Contains similar data elements to the NOE, but includes a through date which is the discharge date.
Entered via Direct Data Entry (DDE).

20. What are the details?
CMS issued CR 8877 providing guidance to the MAC’s
Implementation questions remain…
NOE process has late filing consequences
NOTR is not the same as the final claim
Many questions about the form and process for these new regulations

21. Hospice non-compliance risks
Late filing of NOE
Provider liable days – no payment from date of election until signed NOE is submitted
Other Part A, B and D providers will submit claims that should be the responsibility of the hospice
Late filing of NOTR
Other Part A, B and D providers will not be able to provide services until the patient’s discharge status is updated in CWF

22. Attending physician Attending physician on NOE
Change of Attending Physician form
FY 2015 Final Hospice Wage Index Rule

23. Attending Physician
§ Election of hospice care. (b) Identification of the particular hospice and of the attending physician that will provide care to the individual The individual or representative must acknowledge that the identified attending physician was his or her choice Note: Name of attending physician must be on election form

24. Change of Attending Physician – new form
§ Election of hospice care.
(f) Changing the attending physician.
To change the designated attending physician, the individual (or representative) must file a signed statement with the hospice that states that he or she is changing his or her attending physician.
The statement must identify the new attending physician, and include the date the change is to be effective and the date signed by the individual (or representative).
The individual (or representative) must acknowledge that the change in the attending physician is due to his or her choice.
The effective date of the change in attending physician cannot be before the date the statement is signed.

25. Attending Physician Chosen by the Patient
Attending physician, who may be a nurse practitioner, is chosen by the patient (or his or her representative
Anecdotes:
Hospices changing a patient’s attending physician when the patient moves to an inpatient setting for care, often to a nurse practitioner

26. Who can be a patient’s attending?
Physician with a longstanding relationship with patient Hospice physician or NP Hospitalist, although CMS suggests that the hospice explain to the patient (or representative) that the hospitalist only follows patients who are hospitalized

27. Hospice Non-compliance Risks
Risks for non-compliance:
Hospice changes attending when the patient moves to an inpatient setting for GIP care
Hospice assigns an attending physician to the patient based on whoever is available
Hospice does not get the signature of the attending on the initial certification, unless the attending is an NP

28. Aggregate cap PS&R Inpatient cap
Cap reporting
Aggregate cap
PS&R
Inpatient cap

29. Cap Determination Notice
§ Limitation on the amount of
hospice payments.
(c) The hospice must file its aggregate cap determination notice with its Medicare contractor no later than 5 months after the end of the cap year (that is, by March 31st)
Use data no earlier than three months after the end of the cap period, or January 31
If hospice fails to file, payments will be suspended in whole or in part until cap report is filed
Overpayments will be due when cap report is filed. An Extended Repayment Schedule (ERS) is available.
The MAC will continue to issue final cap determination letter

30. Redesigned PS&R System
Provider Statistical and Reimbursement (PS&R) system
Provides net reimbursement and beneficiary count needed to calculate cap
Enables hospices to to monitor their cap status at different points during the cap year
CMS will provide a proforma spreadsheet for calculating the cap

31. Inpatient days cap & non-compliance risk
MACs will continue to calculate the inpatient days cap
If hospice fails to file the aggregate cap report, payments will be suspended in whole or in part until cap report is filed

32. HIS Hospice CAHPS Survey
Quality reporting
HIS
Hospice CAHPS Survey

33. HIS
§ Data Submission
(a) Submission of Hospice Quality Reporting Program data.
Hospices are required to complete and submit an admission Hospice Item Set (HIS) and a discharge HIS for each patient admission to hospice, regardless of payer or patient age.
The HIS is a standardized set of items intended to capture patient-level data.
2% Penalty for not reporting - Starting FY 2016

34. Newly Certified Hospices
§ Data Submission
(b) A hospice that receives notice of its CMS certification number before November 1 of the calendar year before the fiscal year for which a payment determination will be made must submit data for the calendar year.

35. Public Reporting
Data from CY 2014 (Q3,Q4) will not be used for assessing validity and reliability of the quality measures. Data collected by hospices during Q1-3 CY 2015 will be analyzed starting in CY Decisions about whether to report some or all of the quality measures publicly will be based on the findings of analysis of the CY 2015 data. Public reporting may occur during FY 2017,

36. CAHPS® Hospice § 418.312 Data Submission
(c) Medicare-certified hospices must contract with CMS- approved vendors to collect the CAHPS® Hospice Survey data on their behalf and submit the data to the Hospice CAHPS® Data Center.
2% Penalty for not reporting - Starting FY 2017

37. CAHPS® Hospice Data Collection
Deaths in Prior Calendar Year
Survey and Reporting
< 50 deaths
Exempt from CAHPS data collection and reporting
50 to 699 deaths
n = 2,326 hospices
Survey and report all cases
>= 700 deaths
n = 274 hospices
Sample of 700 will be drawn under equal probability design

38. CAHPS® Hospice Exclusions
Under the age of 18 at the time of death Died within 48 hours of admission to hospice care No caregiver is listed or contact information is not known Primary caregiver is a legal guardian Caregiver has a foreign (Non-US or US Territory address) home address Request not be contacted

39. CAHPS® Hospice Schedule
Send Caregiver Info to Vendor
Data Collection
(by Vendor)
Data Submission (by Vendor)
Dry Run
At least 1 Month First Quarter 2015
Monthly
April - June, 2015
August 12, 2015
Monthly starting April, 2015
June – December, 2015
Quarterly:
November 1, 2015
February 10, 2016
May 11, 2016

40. CAHPS Vendors
Hospices are required to contract with a third- party vendor that is CMS-trained and approved, which ensures that the data are unbiased and collected by an organization that is trained to collect this type of data. 
A list of approved vendors will be provided on the CAHPS® Hospice Survey website closer to national implementation. 
Selection & training Fall 2014

41. Payment Penalty for Failure to Report
§ Determination of payment rates.
(b)(6)
For FY 2014 and subsequent fiscal years, if the hospice does not submit hospice quality data, payment rates are equal to the rates for the previous fiscal year increased by the applicable market basket percentage increase, minus 2 percentage points.
Applies only to the fiscal year involved

42. Quality Reporting Appeals
§ Data Submission
(g) Reconsiderations and appeals of
Hospice Quality Reporting Program decisions.
(1) A hospice may request reconsideration of a CMS decision that the hospice has not met the requirements of the Hospice Quality Reporting Program for a particular reporting period.
Submit a reconsideration request to CMS no later than 30 days from the date identified on the annual payment update notification provided to the hospice.

43. Hospice and Part D

44. Hospice responsibility
Pay for all drugs related to the terminal illness and related conditions Cover medication coverage and management with patient and family during admission process Conduct medication review during admission process and comprehensive assessment Develop a plan for discontinuing medications and communicating discontinuation decisions

45. Buckets of Relatedness
Patient Pays
UNRELATED in 4 categories
May be PART D ELIGIBLE
Related
UNRELATED,
PART D ELIGIBLE
RELATED BUT
NO LONGER MEDICALLY NECESSARY
UNRELATED,
BUT NO LONGER MEDICALLY NECESSARY
Hospice Pays
Part D process for payment (no hospice PA process)
Part D Hospice PA process for payment

46. Buckets of Relatedness
Related to terminal illness
Hospice pays
Related to terminal illness but no longer medically necessary and patient wishes to continue
Patient pays
Unrelated to terminal illness
Part D processes for payment, but no hospice PA process
Unrelated to terminal illness, in 4 categories of drugs, and documented by hospice physician as unrelated
Hospice notifies Part D sponsor proactively
Prior authorization submitted to Part D by hospice provider
Part D may pay
Unrelated but no longer medically necessary
Not covered by hospice
Not covered by Part D
Could be paid for by the patient or discontinued

47. Four Drugs Classes Included in PA
CMS Interim Guidance issued July
Effective October 1, 2014
Prior authorization required for:
Analgesics
Anti-emetics
Laxatives
Anti-anxiety
This DOES NOT MEAN that these four classes is all that the hospice pays for

48. PA Process
Hospice obtains Part D sponsor information from patient Hospice contacts Part D sponsor to provide an oral or written statement about why drug is not related to the terminal illness and/or related conditions. Part D sponsor should accept this information to override the point of sale reject without requiring that the beneficiary, or others, request a coverage determination.

49. Standardized PA form
Current two-page form may be used either by the hospice or prescriber to provide the information necessary to:
satisfy the beneficiary-level prior authorization edit
for the sponsor to make a coverage determination
by the hospice to prospectively communicate information to the Part D sponsor

50. Standardized PA form Page one of form:
Captures the information necessary for the prior authorization of drugs in the four categories
Can be used by the hospice provider to report a beneficiary’s hospice election or termination

51. Standardized PA form Page two of form:
Captures information on drugs related to the terminal illness and/or related conditions
Specifies whether each of these drugs is the responsibility of the hospice or beneficiary.
Hospice providers are not required to complete page two
If hospice chooses to complete, the information will assist Part D plans in care coordination activities.

52. Documentation for Part D
For drugs in the four categories:
a statement on the standardized form indicating the drug is unrelated to the terminal illness and related conditions is sufficient
The statement may be as simple as a “U” or “unrelated”
Hospice physicians must still document in the clinical record, why in their medical judgment, a condition is unrelated.
Medical record must be available to MAC and other auditors to confirm documentation for unrelatedness

53. What is covered under a Part D plan?
Each Part D Plan has its own formulary and many place drugs into different “tiers” on their formularies. Drugs in each tier have a different cost. A Part D drug means a drug that may be dispensed only upon a prescription, is being used for a medically – accepted indication. CMS, What Drug Plans Cover. (2014) coverage.html

54. What is NOT covered under a Part D plan?
Over the counter drugs:
Part D drug does not cover OTCs
Hospice providers should not ask Part D plans to cover OTC vitamins, eye drops, etc… as they do not normally cover these drugs
Inhalers:
Only those accessories for meter dose inhalers (MDIs), Dry Powder Inhalers (DPIs), or Nasal Spray Inhalers (NS) that are included on the NDA or ANDA, listed on the package insert, and specifically packaged with the drug product itself are eligible to meet the definition of a Part D drug CMS.

55. Discontinuing Medications
Care about ALL medications patient is on and WHO prescribed them
Develop process for beginning the discontinuation of medications
Medication review
Patient and family conversation
Process rather than “event”

56. Discontinuing Medications
Decision to discontinue a medication should be clinically based versus financially based.
Article: Discontinuation of statin therapy in patients with limited life expectancy improved overall quality of life without compromising survival. This is the conclusion of a multicenter, unblinded trial that was presented at the annual meeting of ASCO. (Healio, 5/30, asco-2014/discontinuation-of-statin-use-near-end-of-life- improved-qol

57. If the patient stills wants the drug
It is the patient’s liability
No ABN is issued by the hospice
Part D will not cover it
Examples:
Namenda
Statins

58. NHPCO Resources NHPCO website
Regulatory “Hot Topics” – Watch regularly to stay up to date
All Part D relevant information on this page
Current resource - Incorporating Medicare Part D into the Hospice Admissions And Medication Management Process
Look for additional tools and resources to be developed in the coming weeks

59. Hospice is responsible…
Hospice providers are responsible for everything related (including drugs) to the terminal diagnosis and related conditions that contribute to the patient’s terminal prognosis. These diagnoses are recorded on the hospice claim form. Unrelated diagnoses DO NOT go on the claims form, but are documented in the clinical record per the CoPs at §

60. ICD-9-CM/ICD-10-CM Dementia Coding Guidelines
Change Request 8877

61. Coding dementia as a primary diagnosis
ICD-9-CM/ICD-10-CM dementia codes that may not be used as primary diagnoses
Codes that have principal diagnosis code sequencing guidelines.
“Mental, Behavioral, and Neurodevelopmental Disorders” .
Diagnosis codes /F02.80.
Unspecified codes.
These codes are only to be used when the medical record, at the time of the encounter, is insufficient to assign a more specific code.
it is recognized that the underlying neurologic condition causing
dementia may be difficult to code because the medical record may not provide sufficient information.
There are codes listed under “Diseases of the Nervous System” that do provide for appropriate principal code selection under these circumstances and hospice providers are encouraged to look at the coding conventions under that classification for coding dementia conditions on hospice claims.

62. Return to provider claims
When the above diagnoses are reported as a principal diagnosis, the claim will be returned to the provider for a more definitive hospice diagnosis based on ICD-9-CM/ICD-10-CM Coding Guidelines.
Codes that have principal diagnosis code sequencing or etiology/manifestation guidelines.
“Debility” (799.3, /R53.81) and “adult failure to thrive” (783.7/R62.7) are not to be used as principal hospice diagnoses on the hospice claim form.
CR Diagnosis codes in Attachment A
These codes are only to be used when the medical record, at the time of the encounter, is insufficient to assign a more specific code.
it is recognized that the underlying neurologic condition causing
dementia may be difficult to code because the medical record may not provide sufficient information.
There are codes listed under “Diseases of the Nervous System” that do provide for appropriate principal code selection under these circumstances and hospice providers are encouraged to look at the coding conventions under that classification for coding dementia conditions on hospice claims.

63. Clarification - site of service HCPCS codes Q5003 and Q5004
Change Request 8877

64. Correct usage of Q5004 There are 4 situations to use Q5004:
If the beneficiary is receiving hospice care in a solely - certified SNF.
If the beneficiary is receiving general inpatient care in the SNF.
If the beneficiary is in a SNF receiving SNF care under the Medicare SNF benefit for a condition unrelated to the terminal illness and related conditions, and is receiving hospice routine home care; this is uncommon.
If the beneficiary is receiving inpatient respite care in a SNF.

65. Correct usage of Q5003
If a beneficiary is in a nursing facility but doesn’t meet the criteria above for Q5004, the site shall be coded as Q5003, for a long term care nursing facility.

66. Hospice Cost Report
Forms
Instructions

67. Transmittal 1 issued on August 29, 2014
New Cost Reporting Forms And Instructions
Hospice Cost Report changes effective for cost reporting periods beginning on or after October 1, 2014.
The electronic reporting specifications are effective for cost reporting periods beginning on or after October 1, 2014
This transmittal introduces Chapter 43, Hospice Cost Report, (Form CMS – ) which replaces the existing Form CMS –
Link to Transmittal 1
Guidance/Guidance/Transmittals/Downloads/R1P243.pdf

68. Summary of the cost reporting forms
Worksheet S - 2 incorporates data previously reported on the Provider Cost Report Reimbursement Questionnaire, Form CMS
Worksheet A separately identifies general service costs.
Worksheets A - 1 through A - 4 identify direct patient care services by level of care.
Worksheets B and B - 1 separately identify and allocate general service costs by level of care.
Worksheet C calculates per diem costs by level of care.
Worksheet F series provides for reporting of hospice financial data.

70. Always remember
who we serve ---

71. Q&A NHPCO members enjoy unlimited access to Regulatory Assistance
95% of questions received a response in < 24 hours in 2013
Feel free to questions to

72. Regulatory/ Compliance Team at NHPCO
Jennifer Kennedy, MA, BSN, CHC Director, Regulatory and Compliance Judi Lund Person, MPH Vice President, Compliance and Regulatory Leadership us at: 72

73. Resources and References
ICD-9-CM Official Guidelines for Coding and Reporting
assn.org/resources/doc/cpt/icd9cm_coding_guidelines_0 8-09_sm.pdf
Hospice Quality Reporting Program
Patient-Assessment-Instruments/Hospice-Quality- Reporting/index.html
Hospice CAHPS Survey

74. References
The Centers for Medicare & Medicaid Services (CMS) final rule Medicare hospice wage index and Medicare hospice payment rates for fiscal year (FY) 2015
Medicare Benefit Policy Manual, Chapter 9, Coverage of Hospice Services Under Hospital Insurance
Medicare Hospice Conditions of Participation
OIG FY 2014 Work Plan
publications/archives/workplan/2014/Work-Plan-2014.pdf