The CMS proposed rule “Medicare Program; FY2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements; and Updates on Payment Reform.” was released April 29, 2013 and the questions have been frequent per CMS. Though the rule includes no proposed changes for payment reforms presently, it does outline the findings from ongoing data collection, analysis, and provides certain choices being considered for future consideration and review. One of the most frequently asked questions, per CMS, is “When will Medicare Administrative Contractors (MACs) begin returning to provider (RTP) hospice claims that have ‘adult failure to thrive’ or ‘debility’ as the principle diagnosis?” CMS has stated “Soon.”
New Proposed Rule: PAYMENTS ESTIMATED TO INCREASE?
For fiscal year (FY) 2014, CMS currently anticipates hospice payments to increase, on average, a net of 1.1 percent based on the anticipated fiscal year (FY) 2014 hospital market basket update (currently projected at 2.5 percent), reduced by 0.7 percentage points due to reductions mandated by the Affordable Care Act (ACA). Note that CMS reserves the right to notify the industry this summer of a potential re-estimation ofthe hospital market basket and the changes identified in the Affordable Care Act (ACA).
However, Hospices that failed to report quality measures required under the Hospice Quality Reporting Program (HQRP) earlier this year would have their market basket values further reduced by 2 percentage points
Old Rule Now Being Enforced
Hospices that attempt to submit more than one claim per hospice beneficiary per month will have claims returned beginning on dates of service July 1, 2013. This has been a requirement not reinforced, but will have increased reinforcement, per the January 31, 2013 transmittal
New Proposed Rule: LEVELS OF CARE Estimated Payment Rates
Both the Department of Justice and the OIG are monitoring hospices with long lengths of stay at a general inpatient (GIP) level of care. CMS has an even higher focus of care if GIP is provided in inpatient units of hospice.
Given this fact and many others, CMS included as part of the proposed rule estimated FY2014 payment rates for the four payment categories under hospice. Note the table includes the projected payment rates:
Proposed FY2014 Hospice Payment Rates
|Codes||Description||FY2013 payment Rates||Multiply by the FY2014 proposed hospice payment update of 1.8 percent||FY2014 Proposed Payment Rate||Labor Share of the proposed payment rate||Non-labor share of the proposed payment rate|
|651||Routine Home Care||$153.45||x1.018||$156.21||$107.33||$48.88|
|652||Continuous Home Care
Full rate=24 hours of care
$=37.99 hourly rate
|655||Inpatient Respite Care||$158.72||x1.018||$161.58||$87.46||$74.12|
|656||General Inpatient Care||$682.59||x1.018||$694.88||$444.79||$250.09|
You can find the FY2014 hospice wage index values at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/index.html.
Levels of care have been and will be an ongoing focus of scrutiny as seen by the CMS filing of a civil suit against one of the largest providers of hospice services, for “submitting false claims to Medicare for crisis care services that were not necessary, not actually provided, or not performed in accordance with Medicare requirements.” Those requirements necessitate specific documentation. The old adage, “if you did not document it, you did not do it” has real meaning when an agency is attempting to defend itself in this kind of situation.
Old Rule Documentation Requirements.
Be cautious that your general inpatient levels of care (GIP) services documentation can withstand scrutiny:
Prior to transfer to an inpatient setting, ask if the clinical team documented all attempted interventions in the non-inpatient setting and be certain they were documented specifically. Were caregivers involved? Since pain assessment and care is scrutinized, was documentation complete as it related to inpatient care justification? Be specific. Does pain medication administration require skilled clinical intervention not easily or safely completed in the home; ie tubing change? Intensive clinical intervention for significant change in condition such as pathological fracture would require specific documentation but may justify transfer. Also, once admitted to an inpatient setting, initiate the discharge planning process and document the plan. Identify who assisted with the careplan, as well as the expected date of discharge. Again, were caregivers involved?
New Proposed Rule: PAYMENT REFORM DISCUSSION
Though the proposed rule DOES NOT propose payment reform changes at this time, CMS announced it will post the ABT Hospice Study Technical Report on the Hospice Center webpage.
The proposed rule does state future consideration of several potential options for payment reform:
- Use of the initial Medicare Payment Advisory Commission (MedPAC) proposed U-shaped model of March 2009 that oiutlined an increased payment at the beginning and end of an episode of care, with reduced daily payments in the center of the episode
- A possible short-stay add-on to cover the higher costs of patients who are on service for a short time.
- A possible tiered approach to payment with payment based on length of stay.
- CMS is also looking at a potential case-mix based system. It is believed by some that is the reason for the stronger reinforcement of use of more than just a primary diagnosis stated on a claim. CMS stated a recent analysis showed that 4 of 5 hospice claims in 2010 only included the terminal diagnosis out of compliance with ICD-9-CM coding guidelines. CMS has stated that “hospices need to use the ICD-9 coding guidelines when determining the principle diagnosis and all other diagnoses.” In hospice, as in home health, clear coding to the highest level of specificity paints a more complete portrait of the patient and their individualized needs.
A new edit is being considered, which would identify and reject claims without related diagnoses).
New Proposed Rule: REBASING OF ROUTINE HOME CARE
None proposed at this time
CMS RELEASED THE HOSPICE ITEM SET (HIS) draft- It is OASIS-like
Recently, CMS released the Hospice Item Set draft version of assessment forms it expects to be completed for patients on or after July 1, 2014. Section 3004 of the ACA authorizes establishment of a new quality reporting tool/program for Hospices. Per the Hospice Item Set,” For the FY2016 data submission requirements, CMS is proposing that beginning July 1, 2014, each hospice collect data using a n newly created data collection instrument, the Hospice Item Set (HIS).The data item set consists of elements, per CMS, “to collect standardized, pain level data for five domains of care: Pain, Respiratory Status, Medications, Patient Preferences, and beliefs and values.
CMS believes the standardized data collection instrument will allow a more uniform patient-level data collection for quality reporting purposes.
There will be two primary users of this Hospice QRP data; CMS and the public, as the data will all be made available on the CMS Hospice website.
Hospices will submit the data via the Quality Improvement Evaluation System (QIES) Assessment and Processing (ASAP) system for data submission, currently used by Inpatient Rehabilitation (IRFs), Skilled Nursing Facilities (SNFs), and Long Term Care Hospitals (LTCHs).
2014 LOOKS TO BE A VERY BUSY YEAR
There will be an updated OASIS instrument to be implemented. The date and changes are not finalized, but it must be ready for the advent of ICD-10CM which is effective October 1, 2014, which will significantly impact clinical, RCM, and financial processes. And just before ICD-10-CM, starting July 1, 2014, Hospices will be utilizing the new HIS instrument.
Home Health and Hospices will need to start planning NOW for 2014.