The Centers for Medicare & Medicaid Services (CMS) has established a new physician narrative requirement through the August 6, 2009, Federal Register - Medicare Program; Hospice Wage Index for Fiscal Year 2010; Final Rule. As of October 1, 2009, Medicare-participating hospices must include a physician narrative with every certification and recertification of terminal illness for their patients. Hospices, especially smaller ones that depend on volunteer medical directors, may find adhering to the requirements challenging. How well is your organization managing this new requirement?
Before this new requirement the certifying physicians had only to sign and date a standard, generic certification statement indicating their determination that the individuals being certified or recertified for Medicare hospice services had a prognosis of six months or less. The components of the newly implemented CMS requirement can be found on the CMS Web site (PDF, 2.92 MB) and are listed below:
Subpart B--Eligibility, Election and Duration of Benefits
Section 418.22 is amended by adding a new paragraph (b)(3) to read as follows:
Sec. 418.22 Certification of terminal illness.
(b) * * *
(3) The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms.
(i) If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician's signature.
(ii) If the narrative exists as an addendum to the certification or recertification form, in addition to the physician's signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum.
(iii) The narrative shall include a statement under the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient's medical record or, if applicable, his or her examination of the patient.
(iv) The narrative must reflect the patient's individual clinical circumstances and cannot contain check boxes or standard language used for all patients.
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In September 2009, the Health and Human Services (HHS) Office of the Inspector General (OIG) published two studies, one describing Medicare hospice services provided to beneficiaries residing in nursing facilities and the other describing the results of an audit to determine the extent to which hospice claims for beneficiaries in nursing facilities met Medicare coverage requirements in 2006. The OIG found that 31 percent of Medicare hospice beneficiaries resided in nursing facilities in 2006 and that Medicare paid hospices approximately $2.59 billion for their care. Additionally based on a stratified random sample of hospice claims for beneficiaries in nursing facilities in 2006, the OIG reported that 82 percent of hospice claims for beneficiaries in nursing facilities did not meet at least one Medicare coverage requirement. The estimated Medicare payment for these claims was determined to be $1.8 billion. Among the recommendations the OIG made to CMS was to provide tools and guidance to hospices to help them meet the coverage requirements. The full reports are available at the following URLs:
Palmetto GBA will be utilizing the Going Beyond Diagnosis approach to policy and education to help hospice organizations implement the new physician narrative requirements and continuously improve their internal controls. This educational effort will be accomplished through Web-based instruction on how to use the International Classification of Functioning Disability and Health (ICF) to identify, describe and communicate relevant clinical information in support of admissions, recertification and care-planning decisions. The first topic, Going Beyond Diagnosis: Neurological Conditions in Hospice and Palliative Care will be available in December 2009.
If you would like to be notified when the education is made available, please join the RHHI listserv by following the instructions listed below:
- Go to www.PalmettoGBA.com/rhhi
- Click E-mail Updates at the top of the page
- Select Register Now! to create your new member listserv registration. The member registration profile online form will display.
- Complete the seven steps as instructed. Please remember in Step 4 (Specialty listserv) to select Regional Home Health and Hospice Intermediary (RHHI) and then the Hospice category to received hospice-specific information
- After you select the Register button in Step 7, you will receive an e-mail with your username and password for your records
Online Registration Tips
Your username and password must:
- Be a minimum of six characters
- Not contain or use special characters
- Remember that username and passwords are case and character sensitive
In Step 5, when selecting specialty listservs do not type in the text box field. Rather, use the links above the box to modify your selections. This text box field will populate with your listserv selections automatically when you select them from the links above the box.