Hospice is a treatment philosophy that focuses on comfort and quality of life. People are often surprised to learn that it is also a special benefit under Medicare that pays for a great deal more supplies, medications and services than other insurance benefits. Qualifying for hospice care is relatively straightforward. The patient must have Medicare Part A and their physician must certify that they are likely to die within six months if their life-limiting condition runs its expected course. Prognosticating on dying patients, on the other hand, can sometimes be difficult. Research has shown that some patients actually improve with the addition of hospice services and other patients’ rate of decline may be slower than expected. This problem of prognostication is causing hospices to experience increased government scrutiny. At the core of this scrutiny is concern that patients who are receiving hospice care may be chronically ill rather than terminally ill and therefore, ineligible for hospice care. The fact is that hospice serves only about 39% of all dying patients and 50% of those dying patients received care for only three weeks rather than 6 months.
This article deals with the most basic level of hospice scrutiny, Additional Development Requests or ADR’s. ADRs are when the Medicare Fiscal Intermediary or Medicare Administrative Contractor decides to withhold payment on a group of patients until the hospice sends documentation that confirms that the patient met both technical and medical eligibility criteria. If multiple claims are denied, the hospice will experience delays in payment and eventual financial hardship. The end result may be that fewer patients receive hospice care because the hospice becomes fearful that accepting patients early could result in ADRs or audits and subsequent financial hardship.
There are some simple changes in documentation that the hospice clinical staff can make to ensure medical eligibility is well documented and Medicare denials avoided.
First, document at least monthly all significant changes in the patient’s condition that indicate decline especially those outlined by the Local Coverage Determination (“LCDs”) established by Medicare. Play close attention to weight loss or changes in mid-arm circumference measurements. Consider that dysphagia is not just coughing after swallowing but is a constellation of symptoms including: drooling, refusal to eat certain foods, a hoarse voice or gurgling sounds after eating.
Second, avoid generic documentation by closely assessing the patient according to their specific hospice diagnosis. For example, with patients who have end stage heart disease, rather than asking generically about pain, focus your questions on the symptoms you would expect them to have. Ask the following questions: how many pillows do they sleep on at night? Do they wake up at night due to shortness of breath? Do they have a sensation of pressure in their chest and what activities bring on this sensation?
Third, document measurable data instead of observational data. Rather than stating that your patients with chronic obstructive pulmonary disease had difficulty breathing, document measured changes in their respiratory rate (breaths per minute). What was their respiratory rate after walking 20 steps and how many minutes did they require to return to baseline after they rested.
Too many patients are not offered hospice care at the end of life. The end result of this increased Medicare scrutiny of hospices could result in still fewer patients receiving hospice care. Hospices may decide to limit their admissions to those patients that will not cause them either ADRs or audits. Clinical Staff play a key role in preventing this. Simple changes in clinical documentation can demonstrate that hospice patients are in fact declining and therefore eligible and appropriate for hospice care.