Summary at a Glance

Experts Answer Questions on Properly Documenting the Physician Certification of Terminal Illness in New Training

CMS has requested that CGS issue the following revision of their Q&A from their Terminal Illness webinar last month. 

Questions and Answers

We recently received information from the Centers for Medicare & Medicaid Services that telehealth face-to-face visits are acceptable until 12/31/24 and are being evaluated for future use as well. Can you please confirm?

• Correct. Telehealth face-to-face visits are allowed until the end of 2024 and must include both audio and visual components.

If the CTI is not completed by the hospice physician team on the third day after the start of the episode, does the agency perform an administrative discharge and readmit the patient or bill with condition/occurrence code 77 for non-billable days?

• Please refer to the CGS website [r20.rs6.net] for information on untimely certifications and occurrence span code (OSC) 77.

There is no diagnosis code to document when you are using non-disease-specific guidelines, correct? If a provider says the patient is eligible under the non-disease-specific guidelines, finding an ICD-10 to use as primary can be a struggle.

• It's important to be very careful in the interpretation of the Hospice Local Coverage Determination (LCD). The Hospice LCD [r20.rs6.net] provides guidelines for making determinations about whether the patient is terminal (i.e., what to look for and what the reasonable and necessary care is for a terminal patient), which is a benefit access condition. You must have a primary or terminal diagnosis, and non-disease-specific guidelines factor into this primary or terminal diagnosis.

Is continuous home care [r20.rs6.net] available for use if a caregiver is not available to provide care (e.g., the caregiver has surgery)?

• In this circumstance respite care [r20.rs6.net] may be a possible solution.

When using the LCD non-disease-specific guidelines, do you always pick the primary diagnosis as the most likely, even if the patient doesn't exactly meet the disease-specific guidelines for that diagnosis? We see this a lot when patients have a multi-diagnoses reason for qualifying.

• You cannot use the non-disease-specific guidelines alone. You must have a terminal disease listed in the LCD disease-specific guidelines. If the patient has multiple diagnoses, then lean to the one that is having the most effect on the patient.

When a patient elects a primary care provider who is an NP, is the hospice-employed medical director CTI enough or does the NP's overseeing physician need to sign CTI?

• In this circumstance, the hospice-employed medical director's signature is the only one required.

Are co-morbidities required on the CTI?

• Although documenting co-morbidities is not required, doing so is important because it helps to identify why the patient has a terminal prognosis. We recommend that you document comorbidities as they might make the difference between a claim being paid or denied.

Is a physician's order required to do a start of care (SOC) assessment by the registered nurse?

• A verbal order is required within 2 days of an SOC.

Is a new CTI required if a patient transfers to our hospice in the middle of a benefit period, or is the one from the previous hospice sufficient?

• No, a new CTI is not required when transferring agencies.

Can an NP remain as the attending for the patient when they are put on hospice?

• Yes, an NP can be assigned as the attending.

Report: Hospital Capacity Challenges To Drive Expansion Of At-Home Care 

Home Health Care News | By Patrick Filbin
 
A new report found that hospital capacity challenges will persist for the next decade. That, in turn, is a promising sign for more at-home care opportunities in the future.
 
The report — Sg2’s 2023 Impact of Change Forecast — found that hospital capacity challenges will be severely tested, driven by higher patient-acuity levels and staffing shortages.
 
The complexity in patients is one of the driving factors in an increase in case mix index and longer hospital stays. Since 2019, case mix index — a measure reflecting the diversity, complexity and severity of patient illnesses – is up by 5%
 
During the same time frame, the average length of stay for patients admitted to a hospital has risen 10%.
 
Both of those factors have further exacerbated the workforce challenges in the health care space, the authors of the report found.
 
“As the population continues to age and chronic disease incidence rises, we expect increased demand across all sites of care,” Tori Richie, intelligence senior director with Sg2, said in a statement. “The reality is access is a challenge for these patient populations and care redesign will be critical to prevent the acute exacerbation of their medical conditions.”
 
The picture for traditional facility-based settings of care is far from rosy. As the report notes, that should open the door to more care-at-home opportunities.

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Home Health Providers Have 'More Power Than They Did Yesterday' In MA Plan Negotiations 

Home Health Care News | By Joyce Famakinwa

It has become increasingly difficult for home health providers to ignore Medicare Advantage (MA) plans’ growing reach. Providers looking to thrive will need to learn to navigate this evolving reimbursement landscape. 

In 2023, MA plan enrollment surpassed traditional Medicare enrollment. There has been a growth of more than 10 million MA plan enrollees over the last decade.  

“There’s been a lot of celebrity endorsements of Medicare Advantage, a lot of marketing and it’s paid off,” National Association for Home Care & Hospice (NAHC) President William A. Dombi said during a recent MedBridge webinar. 

Home health providers will experience a financial impact from this, as MA plans generally pay less for home health services than traditional Medicare does.  

“This translates to likely losing money on the [MA] program,” Dombi said. “This would require subsidization from other payers. The other payers primarily subsidizing [MA] is the Medicare program, which has had a margin of sorts for many years, but that traditional Medicare margin is shrinking, as there are payment rate cuts, combined with a growing proportion of agency patients coming from [MA].”  

In order to operate successfully, providers will need to have a strong understanding of the business relationship with plans, have a thorough understanding of their contracts and prepare evidence that  

“Imagine saving the MA plan the cost of a hospitalization through your high-quality service that presents a lot of value to the plan, and the opportunity to negotiate a better payment rate,” he said.  

Dombi also noted that providers should have a willingness to consider innovative payment models. 

This could mean episodic contracts rather than per-visit ones. It could also mean capitated payments, where providers take on risk.  

“No matter what model you use, expect to show the financial value to the plan,” Dombi said.  

He also touched the tricky referral dynamics that can occur between MA plans and providers. 

“Many home health agencies accept [MA] patients because their referral sources are saying, ‘You won’t get our traditional patients unless you take the [MA] patients off our hands,’” he said.  

In these instances, it’s important for providers to determine if the organization has enough resources for both types of patients.  

Ultimately, providers should be able to answer the question: Is this MA plan the right fit for your organization? 

“For the first time in years, we are hearing from our members who are actually saying no to plans, because they cannot sustain their existence if they continue to get those rates of payment,” Dombi said. “[This is] creating some negotiating leverage. Clearly, it’s a David and Goliath situation. You don’t have great leverage, but you have more today than you had yesterday.” 

Senate Releases Bipartisan Draft of Emergency Preparedness Bill

Roll Call | By Lauren Clason
 
Draft bill includes provisions on data sharing, state medical stockpiles, wastewater detection and research on treatments for viral pathogens
 
The Senate Health, Education, Labor and Pensions Committee on Monday released a bipartisan draft of a bill to reauthorize a wide-ranging emergency preparedness law, although leaders in both parties are also seeking feedback on two outstanding legislative proposals. 
 
Both chambers are contending with a Sept. 30 deadline to reauthorize the law. Negotiations in the House Energy and Commerce Committee are apparently deadlocked over a rift about prescription drug shortages.
 
The Senate draft includes provisions to launch pilot programs for data sharing and state medical stockpiles, improve wastewater detection capabilities and boost research on treatments for viral pathogens, among other things.
 
But Chairman Bernie Sanders, I-Vt., and ranking member Bill Cassidy, R-La., have yet to reach agreement on other elements they each released separately. 
 
Sanders is seeking feedback on language that would require drug companies to give the U.S. the lowest price offered to other G7 countries if they received support through the Centers for Disease Control and Prevention or the Biomedical Advanced Research and Development Authority. 
 
The provision — known as a “most favored nations” clause — was previously proposed by former President Donald Trump, who never finalized it…

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