Change request 5254 Transmittal 1094, dated October 27, 2006, states that contractors shall calculate the hospice cap amount as instructed in Pub 100-04, Medicare Claims Processing Manual, Chapter 11, Processing Hospice Claims, section 80.2. Based on these instructions the Palmetto GBA Reimbursement department has been performing hospice cap calculations to determine if providers are exceeding the cap. When it is determined that a provider has exceeded the hospice cap an overpayment is assessed.
These overpayments can lead to financial hardships for affected providers. Analysis of providers exceeding the hospice cap point to the following factors as possible causes:
1. Premature admissions into hospice
2. Long lengths of stay
3. Inadequate discharge planning process
4. Providers not monitoring or calculating their own hospice cap
This article will suggest actions providers can take to reduce their risk of exceeding the hospice cap.
Premature Admissions
Hospice providers should have sound clinical admission criteria. The hospice admits a beneficiary only on the recommendation of the medical director in consultation with, or with input from, the beneficiary's attending physician (if any). In reaching a decision to certify that the beneficiary is terminally ill, the hospice medical director must consider at least the following information:
(1) Diagnosis of the terminal condition of the beneficiary.
(2) Other relevant health conditions, whether related or unrelated to the terminal condition.
(3) Current clinically relevant information supporting all diagnoses.
The hospice should also take into consideration any applicable local coverage determinations (LCDs) that may impact the decision. The information must be documented in the medical record.
Decision-making involving conditions not addressed in LCDs, may be facilitated by applying the concepts of Going Beyond Diagnosis®. Palmetto GBA has posted a web-based, educational module titled 'Going Beyond Diagnosis: The Value of ICF' as a way of introducing physicians and Part A providers to the International Classification of Functioning Disability and Health (ICF). The ICF taxonomy can be used to help make semi-structured admissions decisions.
Length Of Stay
Length of stay is negatively impacted by premature admissions, inadequate assessments and lack of discharge planning. Providers must reassess appropriateness of the hospice benefit for beneficiaries on a regular basis. The hospice physician and the interdisciplinary group (IDG) are responsible for establishing a system of communication and integration of services that ensures that the plan of care continues to be reviewed and updated to serve the dying person and his/her family well. There are statutory and regulatory requirements for an IDG approach to caring for the hospice beneficiary. What is critical to hospice care is that the IDG identify through its ongoing assessment when a change is needed to care for the beneficiary, including the appropriateness of discharge and assuring that the beneficiary/family receive the care and services necessitated by the change.
Detailed Discharge Planning Process
Hospice providers should have a detailed discharge planning process in place if it is determined that a beneficiary does not continue to meet the criteria defined by the Medicare hospice benefit. The discharge planning process must take into account the prospect that a beneficiary's condition might stabilize or otherwise change such that the beneficiary cannot continue to be certified as terminally ill. The discharge planning process must also include planning for any necessary family counseling, beneficiary education, or other services before the beneficiary is discharged. This does not mean that each beneficiary will have a discharge plan but that the provider has a process established to address such situations should they arise.
Providers Should Monitor And Calculate The Hospice Cap
In order to assist providers, Palmetto GBA posted an article on the Palmetto GBA Web site titled Update to the Hospice Payment Rates, Hospice Cap, Hospice Wage Index and the Hospice Pricer for FY 2007. This article refers to the instructions given in CR5254 Transmittal 1094, dated October 27, 2006. In addition to this article, CMS posted a MLN Matters article related to the hospice updates which may be accessed at the following link: http://www.cms.hhs.gov/MLNMattersArticles/downloads/mm5254.pdf. These articles include the hospice payment rates for 2007 and the hospice cap information for 2006.
Palmetto GBA is encouraging self-monitoring by the providers that bill for hospice services. The hospice cap is calculated once a year and overpayments are collected if the cap is exceeded. In order to assist providers in self-monitoring, Palmetto GBA has a Hospice Cap/Inpatient Day Limitation Calculator available for use under Tools and Calculators on the Palmetto GBA Website. This is a simple but effective tool that when used correctly allows providers real time information on where they are in relation to the hospice cap.
Reference Web Sites:
www.PalmettoGBA.com
www.CMS.HHS.gov
last updated on 04/27/2007