Source: http://www.nahc.org/NAHCReport/nr140805_1/
Timestamp: 2017-04-28 17:47:51
Document Index: 229576910

Matched Legal Cases: ['§423', '§423', '§418', '§418', '§418', '§418', '§418', '§418', '§405', '§418', '§418', '§418', '§418', '§418']

CMS Issues Final Hospice Payment Rule for FY2015 | National Association for Home Care & Hospice
Per Capita Caps Would Raise Medicare Costs and Harm Home Care 
CMS Issues Final Hospice Payment Rule for FY2015
August 6, 2014 12:38 PM
Late Monday, Aug. 4, the Centers for Medicare & Medicaid Services (CMS) issued a final rule governing hospice payment for fiscal year (FY) 2015. The rule included final payment rate information and policy changes that become effective on Oct. 1, 2014, as well as a summary of public comments submitted earlier this summer and CMS’ responses. For FY2015, the combined impact of market basket changes, legislatively-mandated reductions and wage index changes will net hospices an increase of 1.4 percent. Relative to key hospice policy changes, CMS was response to a number of industry comments. While CMS is finalizing plans to impose timeframes for submission of the hospice notice of election (NOE) and a notice of termination or revocation (NOTR) if the hospice has not submitted a final claim, it has set the time frame at 5 days following the effective date of election or date of termination/revocation as compared with a proposed 3-day time frame. CMS also finalized a proposal requiring hospices to calculate and file (along with any overpayment due) their aggregate cap determinations within 5 months of the close of the cap year but decided against requiring hospices to calculate their inpatient caps. CMS also finalized its proposed requirement relative to inclusion of the patient or representative’s choice of attending physician on the hospice election statement (as well as documentation of a change in attending). All of these changes are effective Oct. 1, 2014.
The National Association for Home Care & Hospice (NAHC) is conducting analysis of the final rule and will be providing additional coverage in future issues of NAHC Report. FY2015 Hospice Final Medicare* Payment Rates Updated by the Proposed Hospice Payment Update Percentage (for hospices that successfully meet quality reporting requirements) Code
FY2014 Payment Rates
Multiply by the FY2015 final hospice payment update of 2.1 percent
Labor (adjusted by wage index)/
Non-labor percentage
FY2015 FINAL Payment Rate FY2015 Preliminary Payment Rate
X1.021
68.71 percent/
31.29 percent
$38.71 hourly rate
$910.78
54.13 percent/
45.87 percent
64.01 percent/
35.99 percent
*Final rates do not reflect the 2% sequester. Medicaid rates differ slightly and will be issued by CMS in the near future.
Please note: Hospices failing to meet applicable quality reporting requirements will receive the following rates for FY2015:
RHC$156.22
CHC$911.69
IRC$161.58
GIP$694.88
SUMMARY of FINAL FY2015 HOSPICE PAYMENT RULE
Medicare Program; FY 2015 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements and Process and Appeals for Part D Payment for Drugs for Beneficiaries Enrolled in Hospice-- FINAL RULE (please note: link to display copy will expire after final rule is published in Federal Register on Aug. 22, 2014)
Rates and Aggregate Cap
Estimated hospital market basket update: 2.7 percent
Impact of ACA Reductions: minus 0.7 percentage point
Impact of Wage Index Changes(6th year of BNAF phase out and wage index changes): minus 0.7 percentage point
NET UPDATE: 1.3 percent
NET UPDATE WITH Sequester (minus 2 percent )= minus 0.7 percent
Aggregate cap amount: $26,725.79.
Estimated FY2015 Medicare rates (excludes impact of sequester) for hospices meeting quality reporting requirements:
RHC $159.18
CHC 929.00 ($38.71 hourly rate)
IRC 164.65
GIP 708.07
Final hospital market basket update: 2.9 percent
ACA reductions: minus 0.8 percentage points
Wage index changes: minus 0.7 percentage point
NET UPDATE: 1.4 percent
NET UPDATE with Sequester (minus 2 percent) = minus 0.6 percent
Aggregate cap amount: $26,725.79
Final Medicare payment rates by level of care for hospices meeting quality reporting requirements (excludes impact of sequester):
RHC $159.34
CHC 929.91 ($38.75 hourly rate)
IRC 164.81
GIP 708.77
(Medicaid rates may vary slightly and will be posted to CMS Hospice Center website)
Wage Index Files: Available online at: https://www.cms.gov/Center/Provider-Type/Hospice-Center.htmlin the SPOTLIGHT section
Definition of “terminal illness”
CMS ASKED FOR COMMENT FOR POSSIBLE FUTURE RULE-
“terminal illness” to mean: “Abnormal and advancing physical, emotional, social and/or intellectual processes which diminish and/or impair the individual’s condition such that there is an unfavorable prognosis and no reasonable expectation of a cure; not limited to any one diagnosis or multiple diagnoses, but rather it can be the collective state of diseases and/or injuries affecting multiple facets of the whole person, are causing progressive impairment of body systems, and there is a prognosis of a life expectancy of six months or less”.
No specific action at this time but CMS will consider the comments and issues raised for possible future rulemaking.
Definition of “related conditions”
CMS SOLICITED COMMENT
FOR POSSIBLE FUTURE RULE-MAKING
“Those conditions that result directly from terminal illness; and/or result from the treatment or medication management of terminal illness; and/or which interact or potentially interact with terminal illness; and/or which are contributory to the symptom burden of the terminally ill individual; and/or are conditions which are contributory to the prognosis that the individual has a life expectancy of 6 months or less”
No specific action at this timebut CMS will consider the comments and issues raised for possible future rulemaking.
Reminder regarding documentation of eligibility
Hospices are reminded that certifying physician should use their best clinical judgment in determining eligibility and the hospice medical director must consider at least the following information per 418.25(b):
• Diagnosis of the terminal condition of the patient.
• Other health conditions, whether related or unrelated to the terminal condition.
• Current clinically relevant information supporting all diagnoses.
This information must be in the record and it is the hospice’s responsibility to make certain that the physician's clinical judgment can be supported by clinical information and other documentation that provide a basis for the certification of 6 months or less if the illness runs its normal course.
CMS expects documentation supporting a 6-month or less life expectancy will be included in the beneficiary’s medical recordand available to the MACs when requested.
Hospice medical director must assess and evaluate the full clinical picture of the Medicare hospice beneficiary to make the determination whether the beneficiary still has a medical prognosis of 6 months or less, regardless of whether the beneficiary has stabilized or improved.
CMS SOLICITED COMMENTS ON CODIFICA-TION OF ELEMENTS OF MARCH 10 GUIDANCE FOR FUTURE RULE-MAKING
Soliciting commentson whether CMS should incorporate elements of the guidance (issued in March 2014) to Part D plans requiring prior authorization for drugs for hospice patients as part of actual regulations that would be binding on Part D plans. The guidance includes processesto be utilized by Part D plans to address the inappropriate Part Dreimbursement for medications that should be covered under the Medicare hospice per diem. CMS is considering:
1. Amending §423.464 by adding a new paragraph (i): “Coordination with Medicare hospices,” which would require that a Part D sponsor communicate and coordinate with Medicare hospices in determining coverage for drugs whenever a coverage determination process is initiated or a hospice furnishes information regarding a beneficiary’s hospice election and/or drug profile.
2. Requiring that a Part D sponsor determine Part A versus Part D coverage at point-of-sale for any drugs for beneficiaries who have elected the hospice benefit as of the date the prescription is presented to be filled. This would codify the PA process pretty much as it is written in the March 10, 2014 memo from CMS regarding final guidance to hospices and Part D sponsors. 3. Requiring that a Part D sponsor process retrospective claims adjustments and issue requests for repayment and or refunds for drugs that are excluded from Part D by virtue of their being covered under the hospice benefit in accordance with the timeframes in §423.466(a). The amount requested for repayment and subsequently repaid would be the total amount paid to the pharmacy, including the negotiated price for the drug paid by the Part D sponsor, the beneficiary cost sharing and any other payments made on the claim as reported by the sponsor on the prescription drug event record to CMS. Under this process, the Part D plan would be responsible for repaying the beneficiary and/or the hospice for medications that should have been covered under Part D. Subsequent to issuance of the final rule, CMS issued revised guidance July 18, 2014) instructing Part D plans to limit prior authorization (PA) requirements for drugs prescribed for hospice patients to four classes of drugs(analgesics, antinauseants, laxatives, and antianxiety drugs). This guidance is effective Oct. 1, 2014, and will remain in force until other requirements are finalized.
CMS will consider comments provided on the changes it is considering as part of future rulemaking.
Timeframes Proposed for Filing NOE and NOTR
(1) That hospices be required to file the NOE with its MAC within 3 calendar days after the hospice effective date of election, regardless of how the NOE is filed (by direct data entry, or sent by mail or messenger).
Hospices not filing within the required 3 calendar days would not receive payment from the effective date of election to the date the NOE is filed – would be hospice responsibility and cannot bill beneficiary for them
(2) Hospice must file a notice of termination/revocation (NOTR) within 3 calendar days after the patient’s revocation/discharge date
Require that hospices file the NOE within 5 calendar days after the effective date of election and file the NOTR within 5 calendar days after the date of discharge or revocation (unless hospice has already submitted a final claim). If an NOE is not filed timely, the hospice will be ineligible for paymentfrom the effective date of election until the day the NOE is received by the MAC.
A timely-filed NOE is one that is submitted to, and accepted by, the MAC within 5 calendar days after the effective date of election. A timely-filed NOTR is one that is submitted to, and accepted by, the MAC within 5 calendar days after the effective date of discharge or revocation. CMS finalizes an exceptions policy for failure to meet timely filing of the NOE; a hospice may be eligible for an exception to the consequences of late filing of the NOE if it documents and requests an exception based on 4 circumstances listed below and the MAC grants the exception:
1. Fires, floods, earthquakes, or other unusual events that inflict extensive damage to the hospice’s ability to operate;
2. An event that produces a data filing problem due to a CMS or MAC systems issue beyond the control of the hospice;
3. A newly Medicare-certified hospice that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its MAC; or
4. Other circumstances determined by CMS to be beyond the control of the hospice.
MACs will provide hospices with information about exceptions process/policies.
NO consequences for late filing of NOTRwill be imposed at this time.
CMS will explore potential to batch file NOEs.
PROPOSED ADDITION OF ATTENDING PHYSICIAN TO HOSPICE ELECTION FORM
To amend the regulations at §418.24(b)(1) and require the election statement to include the patient’s choice of attending physician
Information identifying the attending physician should be recorded on the election statement in enough detail so that it is clear which physician or NP was designated as the attending physician. Hospices have the flexibility to include this information on their election statement in whatever format works best for them, provided the content requirements in §418.24(b) are met.
Language on the election form should include an acknowledgement by the patient (or representative) that the designated attending physician was the patient’s (or representative’s) choice.
If a patient (or representative) wants to change his or her designated attending physician, he or she must follow a procedure similar to that which currently exists for changing the designated hospice. Specifically, the patient (or representative) must file a signed statement, with the hospice, that identifies the new attending physician in enough detail so that it is clear which physician or NP was designated as the new attending physician.
The statement needs to include the date the change is to be effective, the date that the statement is signed, and the patient’s (or representative’s) signature, along with an acknowledgement that this change in the attending physician is the patient’s (or representative’s) choice. The effective date of the change in attending physician cannot be earlier than the date the statement is signed.
CMS finalizes proposed changes.
CMS will amend the regulations at §418.24(b)(1) and require the election statement to include the patient’s choice of attending physician
Information identifying the attending physician should be recorded on the election statement in enough detail so that it is clear which physician or NP was designated as the attending physician.Hospices have the flexibility to include this information on their election statement in whatever format works best for them, provided the content requirements in §418.24(b) are met.
CMS provides clarification that attending physician status need not change when a patient enters GIP. If attending physician is not available, hospice physician fills in.
Hospice should document in medical record situations where attending is no longer willing or available to follow patient. Hospice should inform patient or representative that new attending may be chosen.
CMS will issue educational materials to alert hospices and treating physicians about inappropriate use of attending physician modifier on claim and update beneficiary materials.
CAP Determinations and Overpayments
CMSproposes to:
(1) Amend §418.308 to require that hospices complete their inpatient and aggregate caps determination within 5 months after the cap year ends (that is, by March 31) AND remit any overpayments at that time.
(2) Require the MACs to then reconcile all payments at the final cap determination.
(3) Further amend §418.308 and §405.371 to state that payments to a hospice would be suspended, in whole or in part, for failure to file a self-determined inpatient and aggregate cap determination within 150 days after the end of the cap year
Hospices would be provided a pro-forma spreadsheet that they would use to calculate their caps to remit any overpayments.
This is similar to the current practice followed by all other provider types that file cost reports with MACs.
CMS is finalizing the proposal to require hospices to submit the aggregate cap calculation no later than 5 months after the end of the cap year and refund any overpayment with the filed cap determination. CMS is NOT requiring that hospices calculate their inpatient cap, given concerns about the complexity of this calculation and the limited number of hospices that exceed the inpatient cap.
CMS will require hospices to wait at least 3 months following the end of the cap year to calculate the self-determined aggregate cap.
Hospices that fail to file their self-determined aggregate cap determination will have payments suspended.
Pro forma spreadsheet will be made available from CMS.
(1) To codify the HIS submission requirements at §418.312
(2) To permit newly certified hospices receiving notice of their CMS certification number on or after Nov. 1, 2014, to be excluded from the quality reporting requirements for the FY 2016 payment determination. Data submission and analysis would not be possible for a hospice receiving notification of their certification this late in the reporting time period.
(3) For future years, CMS proposes that hospices receiving notification of certification on or after Nov. 1 of the preceding year involved, be excluded from any payment penalty for quality reporting purposes for the following fiscal year.
(4) CMS proposes granting itself the authority to make accommodations in the case of natural disaster or other extenuating circumstances (common with other quality reporting programs); propose a process, for the FY 2016 and subsequent payment determinations, for hospices to request and for CMS to grant extensions/exceptions with respect to the reporting of required quality data when there are extraordinary circumstances beyond the control of the provider.
When an extension/exception is granted, a hospice will not incur payment reduction penalties for failure to comply with the requirements of the HQRP.
Under the proposed process for the FY 2016 payment determination and for subsequent payment determinations, a hospice would submit a written request to CMS. Requirements for requesting an extension/exception will be available on the Hospice Quality Reporting Web site at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting​/index.html.
(5) CMS proposes that the reconsiderations and appeals process for hospices that fail to meet the Hospice CAHPS® data collection requirements be part of the Reconsideration and Appeals process already developed for the Hospice Quality Reporting Program.
(6) CMS further proposes to codify the process for filing a request for reconsiderations of a CMS-imposed reduction of 2 percentage points, which can be found at §418.312.
Soliciting commentson future measure development –CMS sees two primary opportunities: to expand measures already in use in other quality reporting programs that could apply to the HQRP and to develop new measures. CMS is particularly interested in pain and symptom management, as well as in patient-reported outcomes. CMS will:
(1)Codify requirements for HIS submission
(2)Permit newly certified hospices receiving notice of their CMS certification number on or after Nov. 1, 2014, to be excluded from quality reporting requirements for FY2016 payment determination.
(3)Set in regulation that hospices receiving notification of certification on or after Nov. 1 of the preceding year involved would continue to be excluded from any payment penalty for quality reporting purposes for the following FY.
(4)Allow hospices to request, and for CMS to grant, extensions/exceptions for reporting of required quality data when extraordinary circumstances beyond control of provider arise.
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CMS finalized planned implementation of hospice CAHPS as proposed.
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Future measure development -- CMS solicited comments in proposed rule and continues to have an interest in receiving feedback on future measure development. Update on the Inter-
national Classification of
Diseases, 10th Revision, Clinical Modification (ICD-10-CM) and Coding Guidelines for Hospice Claims Reporting
CMS adviseshospices to pay close attention to the various coding and sequencing conventions found within The Official ICD-9-CM Guidelines for Coding and Reporting when reporting diagnoses on hospice claims.
CMS will implementcertain edits from Medicare Code Editor (MCE), which detect and report errors in the coding of claims data, for all hospice claims effective October 1, 2014 (for those claims submitted on or after October 1, 2014). Hospice claims containing inappropriate principal or secondary diagnosis codes, per ICD-9-CM coding conventions and guidelines, will be returned to the provider and will have to be corrected and resubmitted to be processed and paid. CMS will implement edits related to etiology /manifestation code pairs from the MCE
Analysis conducted on FY 2013 hospice claims shows that 67 percent of hospice claims still only report a single, principal hospice diagnosis.
CMS reminds hospices that all diagnoses should be reported on the hospice claim for the terminal illness and related conditions, including those that can affect the care and management of the beneficiary. CMS will continue to monitor hospice claims to see if all conditions are being reported as required by ICD-9-CM Coding Guidelines Hospices should continue to work towards getting this information correct and on the claims prior to October 1, 2014 when the MCE edits go into effect for hospices.
CMS will implementcertain edits from Medicare Code Editor (MCE), which detect and report errors in the coding of claims data, for all hospice claims effective October 1, 2014 (for those claims submitted on or after October 1, 2014). Hospice claims containing inappropriate principal or secondary diagnosis codes, per ICD-9-CM coding conventions and guidelines, will be returned to the provider and will have to be corrected and resubmitted to be processed and paid. CMS will implement edits related to etiology /manifestation code pairs from the MCE. Effective for all claims received Oct. 1, 2014 or afterward, CMS will RTP hospice claims using “debility” or “adult failure to thrive” as the principal diagnosis. Additionally, CMS will RTP claims using an inappropriate dementia code as a principal diagnosis-- including those that require that the underlying causal condition be coded first. CMS will also implement edits from the MCE that will detect and report errors in the coding of claims. These edits will result in hospice claims containing inappropriate principal or secondary diagnosis codes, per ICD-9-CM coding conventions and guidelines, to be RTPd.
CMS will implement edits related to etiology/manifestation code pairs from the MCE. These conventions require that the underlying cause (etiology) be sequenced first.
CMS will incorporate new edits to the MCE that will enforce sequencing guidelines for several dementia codes under “Mental, Behavioral, and Neurodevelopmental Disorders” that are not currently addressed under the MCE.
CMS reminds hospice providers to include ALL appropriate diagnoses that describe a patient’s terminal condition and related conditions on claims.
Technical Regulatory Text Change PROPOSAL
CMS proposes to:
Make a technical correction in §418.3 to delete the definition for “social worker.” This definition is no longer accurate, and CMS intended to remove it as part of the June 5, 2008 final rule that amended the conditions of participation (CoPs) for hospices (73 FR 32088). The 2008 final rule established new requirements for social workers at §418.114(b)(3), making the definition of “social worker” at §418.3 obsolete. However, the technical amendatory language included in the 2008 final rule did not instruct the Federal Register to delete the “social worker” definition. CMS proposes this technical correction in order to remedy this oversight.
Section 418.3 states Social workermeans a person who has at least a bachelor's degree from a school accredited or approved by the Council on Social Work Education.
CMS is finalizing this change.