Hospice Information Set Administrative Guide · A2115 – Reason for Discharge Section F – Preferences questions are as follows: F2000A-B - CPR Preference, Date asked about CPR

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Consolo HIS Administrative Guide June 2014 1 | P a g e

Hospice Information Set Administrative Guide

This guide will explain Consolo functionality for aggregating and extracting Hospice Information Set (HIS) data. Additional important information can be found in other user guides in Training Tools / Reference Documents. Additionally, this functionality may be enhanced by periodic updates to Consolo’s software. While we endeavor to keep these manuals up to date, in order to stay abreast of current functionality, you should always review the Release Notes, and attend pre-release training, whenever a new version of Consolo is released. Background

The Hospice Item Set (HIS) is a group of 7 Quality Measures developed by the National Quality Forum (NQF) approved by CMS to be included in all Hospice clinical charting effective July 1, 2014. Consolo has been working diligently to address these measures. A review of the measures and CMS-mandated information follows here:

The Nation Quality Forum (NQF) Defined the Following Standards to be tracked in the Hospice Item Set (HIS) data: • NQF 1641 - Treatment Preferences • Modified NQF 1647 - Beliefs/Values Addressed • NQF 1634 and NQF 1637 - Pain Screening and Pain Assessment • NQF 1639 and NQF 1638 - Dyspnea Screening and Dyspnea Treatment • NQF 1617 – Patients Treated with an Opioid who are Given a Bowel Regimen Each measure statement is specific for what is to be asked of the patient/CG by Hospice staff and the data each measure collects. A Hospice Item Set manual was developed by CMS with instructions on what the specific questions would comprise each Quality Measure. The manual organizes the Item Completion Conventions as follows:

Section A: Administrative Information

Section F: Preferences

Section I: Active Diagnoses

Section J: Health Conditions

Section N: Medications

Section Z: Record Administration Each one of these sections contains the specific questions related to the measure addressed.

Please refer to the Hospice Item Set Manual in Help/Reference Documents for specifics in each

question.

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Section A – Administration Information questions are as follows:

A0050 – Type of Record

A0100 – Facility Provider Numbers

A0205 – Site of Service on Admission

A0220 – Admission Date

A0245 – Date of Initial Nursing Assessment

A0250 – Reason for Record (Admission or Discharge)

A0270 – Discharge Date

A0500 – Legal Name of Patient

A0600 – Social Security and Medicare Numbers

A0700 – Medicaid Number

A0800 – Gender

A0900 – Birth Date

A1000 – Race/Ethnicity

A1802 – Admitted From

A2115 – Reason for Discharge Section F – Preferences questions are as follows:

F2000A-B - CPR Preference, Date asked about CPR Preferences

F2100A-B – Other Life-Sustaining Treatment Preferences, Date asked about Life-Sustaining Treatment Preferences

F2200A-B – Hospitalization Preference, Date asked about Hospitalization Preference

F3000A-B – Patient/CG asked about Spiritual/Existential Concerns, Date first asked about Spiritual/Existential Concerns

Section I – Active Diagnoses questions are as follows:

I0010 - Principal Diagnosis Section J – Health Conditions questions are as follows:

J0900A-D – Pain Screening, Date of Screening, Severity, Type of Standardized Tool

J0910A – Comprehensive Pain Assessment – includes Location, Severity, Character, Duration, Frequency, What Relieves or Worsens, Effect on Quality of Life, None of the Above

J0910B - Date of Assessment

J2030A-C – Screening for Shortness of Breath, Date of Screen, Result of Screening (skip instructions if screening response is No to N0500)

J2040A-C – Treatment for Shortness of Breath (if response is No skip to N0500), Date of Assessment, and Type of Treatment

Section N – Medications

N0500A-B – Was a Scheduled Opioid initiated or continued, Date of Scheduling

N0510A-B – Was a PRN Opioid initiated or continued, Date of PRN order

N0520A-B – Was a Bowel Regimen initiated or continued, Date of order Section Z – Record Administration

Z0400 – Signatures of Person(s) completing the Record

Z0500A-B – Signature of Person Verifying Record, Date of Signature

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Submission of HIS Data As of May 2014, the CMS website for reporting Hospice Item Set data is: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/ Hospices may sign-up for data submission via this website address: https://www.qtso.com Training on data submission can be obtained via this website address: https://www.qtso.com/hospicetrain.html

As of this date, CMS has NOT approved third-party reporting (Consolo reporting data in lieu of its users). This means that each Hospice must establish their own QTSO account and report data directly via the above website address. Completion Timing for HIS records:

For HIS-Admission records (A0250 = 1) the Completion Date (Z0500B) may be no later than 14

days from the Admission Date (A0220). Therefore, Z0500B (Completion Date) minus A0220 (Admission Date) should be less than or equal to 14 days.

For HIS-Discharge records (A0250 = 2) the Completion Date (Z0500B) may be no later than 7

days from the Discharge Date (A0270). Therefore, Z0500B (Completion Date) minus A0270 (Discharge Date) should be less than or equal to 7 days.

Submission Timing for HIS records:

All HIS records should be submitted electronically to the QIES ASAP system within 30 days of the Event Date. The Event Date for a HIS-Admission record is the Admission Date (A0220) and for a HIS-Discharge record is the Discharge Date (A0270).

For HIS-Admission records (A0250 = 1) the Submission Date may be no later than 30 days from

the Admission Date (A0220). Therefore, the Submission Date minus the Admission Date (A0220) should be less than or equal to 30 days.

For HIS-Discharge records (A0250 = 2) the Submission Date may be no later than 30 days from

the Discharge Date (A0270). Therefore, the Submission Date minus the Discharge Date (A0270) should be less than or equal to 30 days.

https://www.qtso.com/

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Correcting Errors in HIS Records That Have Been Accepted into the QIES ASAP System:

Hospices should correct any errors necessary to ensure that the information in the QIES ASAP system accurately reflects the patient’s hospice record. Inaccurate information in the QIES ASAP system may affect hospice quality reporting results. A HIS record may be corrected even if subsequent records have been accepted for the patient. An error identified in a QIES ASAP system HIS record must be corrected. Inaccuracies can occur for a variety of reasons, such as transcription errors, data entry errors, software product errors, item coding errors, or other errors. The following two processes exist for correcting HIS records that have been accepted into the QIES ASAP system: • Modification Request

• Inactivation Request Completion of a Modification Request record will archive the inaccurate HIS record within the QIES ASAP system and replace the record with the new, corrected record. Completion of an Inactivation Request will also archive an inaccurate HIS record within the QIES ASAP system, but will not replace the record with the new record.

Please review the HIS Manual for more information on the Modification/Inactivation Requests (Pages 3-5 to 3-9). These requests will be handled internally by each hospice; Consolo program will not be involved in this process.

Clinical Charting Review

See the HIS Clinical Reference Document for full details. Required HIS questions are located within the

various relevant clinical chart sections. Consolo will automatically extract the answers to these questions

and compile them in the HIS Clinical Summary screen on each patient’s homepage:

Clinicians just need to complete their routine admission and discharge charting in the “Clinical Charts”

area of the patient homepage, making sure to complete the required HIS questions. Consolo will compile

the information for them. Hospice agencies can facilitate this process by creating Encounter Types for

clinicians to use. This is covered in a separate Reference Document.

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HIS Administrative Functionality

HIS Clinical Summary Screen

Located on patient homepage, the HIS Clinical Summary screen displays a summary for this patient:

Consolo will automatically generate an Admission and Discharge HIS Item. Users with role permissions

may create modified (corrected) HIS Items if necessary.

“HIS Data for new Admission…” links to the patient’s care level change.

Patient name links to patient’s homepage.

Missing Data: Is this HIS item missing required information?

Verified: Has someone verified the data contained in this HIS item? This is a required

pre-submission step, wherein a Hospice representative attests to the accuracy of the HIS

information. Note: Only signed/verified HIS items can be batched and submitted.

Batched: Has this HIS Item been included in a batch? A batch is a collection of HIS items for

multiple patients.

Submitted: Has this HIS item been submitted to CMS? Note: As of xx/xx/xxxx CMS has not

created a method for vendor-facilitated submissions. We anticipate that they will, but at

this time the Submission functionality is not present in Consolo.

Create modification: Click to create an updated HIS. NOTE: this feature should ONLY be used

if the HIS item in question has already been verified, batched, and submitted. Until that

point, the HIS will automatically update based on changes to the patient’s medical record.

Once the HIS item has been batched and submitted, however, it is “locked” and will no

longer update. If corrections are needed thereafter, the “create modification?” feature may

be utilized.

Create inactivation: Click to create an inactivation message for this HIS Item. NOTE: Similar to a

modification, but batching and submitting an Inactivation will remove a previously sent

HIS Item from the CMS database.

View: Click the eyeball to view the information contained in this HIS item.

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Viewing the HIS Details Screen

Clicking the View icon on the HIS Clinical Summary screen provides a detailed view of all the data

contained in the selected HIS item:

Each HIS Item Code and description are listed in the left most columns.

The value to be sent, and a description of the value, are in the next two columns.

The signature of the clinician who charted the information is listed in the next column. NOTE:

CMS requires hospices to maintain a record of the signatures of the clinician(s) who

answered each clinical HIS question.

Click the View icon to view the underlying record from which the HIS data comes from. In the

screenshot above, clicking the View icon next to “A0245 | Date initial nursing assessment

initiated” will open up the specified nursing assessment clinical chart.

Clicking the Edit icon will allow a user to edit the underlying record. This is dependent on two

factors, however: if the underlying record is electronically signed, it may not be edited. If it is

unsigned, but the user doesn’t have role permissions to edit, the underlying record will also be

uneditable.

Missing or incomplete items are in red:

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Verifying a HIS Item

Before a HIS can be batched or submitted, it must be verified. There are two methods for verifying a HIS

Item. Method two is discussed later. Method one: from the HIS Details screen, click Related Links and

then Add Your Signature:

Note: By Verifying a HIS, you are agreeing to the following attestation:

This attestation will appear on the signed HIS:

Note: HIS Items must be verified/signed in order to be batched and submitted.

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HIS Report

This report is located under the Admin menu:

Filter Options:

Date Range: search for patients admitted or discharged within the specified range.

Offices: search for patients from any combination of offices.

Patient: search only for a specific patient.

Team: search only for patients assigned to a specific team.

Missing data: search for any HIS item, only those that are missing data, or only those that are

complete.

Include Pediatric Patients: Medicare does not require HIS data for pediatric patients at this time.

However, Consolo still gathers the information in case this is required in the future.

Include Not Verified: Include HIS Items that are missing a verification signature.

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HIS Report Cont.

The completed report will appear like this:

Effective Date: Effective Date of the specified HIS Item.

Office: Office to which the patient is assigned.

Type: What type of HIS Item is this? Admission or Discharge.

Missing Data: Is the HIS Item missing any data? NOTE: It may be appropriate for a HIS Item to

be missing data, for example if a specific question did not apply to the patient.

Submitted: Has this HIS Item been submitted to CMS? NOTE: This functionality is not yet

enabled.

Batched: Has this HIS Item been included in a Batch?

Verified? Is the specified HIS Item verified? NOTE: HIS Items must be verified in order to be

batched/submitted.

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Verifying HIS Items from the HIS Report

If the completed HIS Report includes unverified HIS Items, they may be verified here. This process is

similar to Approving time on user time sheets.

Check the box next to any HIS Items you wish to verify.

Click the “Verify Selected” button. NOTE: This will apply your signature, along with the HIS

Attestation statement (see page 4) to each selected HIS Item.

Alternatively, clicking the “Verify All” button will verify ALL un-verified HIS Items included in the

report. NOTE: This will apply your signature, along with the HIS Attestation statement (see

page 4) to each selected HIS Item.

If HIS Items are verified from the HIS Report, please re-run the report in order to include the now-verified

items in a batch.

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Creating a HIS Batch

Once the desired group of HIS Items has been verified, click “Create Hospice Item Set Batch” button.

The verified HIS Items will now be “Batched.” This is similar to “Locking” a payroll report. Once included in

a Batch, HIS Items are locked. The data within them will no longer change, even if the underlying records

are changed.

The HIS Items may now be downloaded to your computer by clicking the “Download Zip File” button. The

Zip file contains the selected HIS Items properly formatted for submission to CMS.

Accessing Completed Batches

Once batched, included HIS Items are locked, and their content remains static. They can be retrieved at

any time from the Admin Menu / Hospice Item Set Batches:

Click the View Icon to view the included HIS Items.

This screen provides information about the date batches were created, the person who created

the batch, the users who verified the HIS Items within each batch, and eventually, information

about Submission to CMS.

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Creating a Modified Entry

If a HIS Item has been batched, it may not be modified. If a batched HIS Item is incorrect or incomplete, a

Modified HIS Item may be created. Start on the patient’s HIS Clinical Summary Screen:

Click the “Create Modification?” button to display the currently-batched HIS information:

Then click the “Edit” Icon next to the item(s) to be corrected:

A new browser tab will open with the proper form (Personal Information in this example). Add or correct

the necessary information:

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Creating a Modified Entry, Cont.

Once all modifications have been made, click the “Create Modification” button at the bottom of the

screen:

Apply your electronic signature after reviewing for completeness:

The Modified HIS Item appears on the patient’s clinical summary screen like so:

The modified record may now be batched and exported for submission to CMS by running the HIS Report

as described earlier:

The Modified HIS Item is now available to be batched.

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Tracker Dashboard

To assist with monitoring HIS reporting compliance, the Tracker Dashboard has been modified.

NOTE: The Referral, Admissions, Discharge, Care Level Change, and Certifications Tabs now

report activity within a FOURTEEN DAY RANGE. Previously they reported a 10 day range.

Columns have been added displaying the deadline for completing (assessing and recording) the HIS

information, and for submitting (when the data must be sent to CMS) the completed HIS Item to CMS.

The Tracker will also report whether or not the HIS Item is missing data, or has been verified. The View

Icon may be clicked in order to immediately view the patient’s HIS Item. Submitted functionality is still

pending:

NOTE: Admission HIS Items must be completed within 14 days of admission. Discharge HIS

Items must be completed within 7 days of discharge. Both must be submitted to CMS within 30

days of admission or discharge, respectively.

Permissions

The following section of new permissions are required in order for any Role to perform HIS related

functions. Please add them to necessary Roles under the Admin menu. Edit desired roles and add:

Also, in Clinical Charts: “View Hospice Item Set Data” and in Clinical Reports: “Hospice Item Set”.