How to Better Manage Physician Services in Hospice · 418.25 Admission to Hospice Care • “The hospice admits a patient only on the recommendation of the medical director in consultation

How to Better ManagePhysician Services in Hospice

Lauren Templeton, DO HMDCHospice Medical Director

Objectives• Clarify the physician role in determination of eligibility,

relatedness and medical coverage • Discuss physician opportunities to drive clinical care and lead

the interdisciplinary group• Address physician involvement in auditing process

Admission and the Physician• Determination of eligibility with prognosis of less than 6 months• Determination of terminal illness–Evaluation of related comorbidities and secondary conditions–Documentation of unrelated conditions –Certification of Terminal Illness

• Medication Coverage & Deprescribing• Review of admission with interdisciplinary group –Update to the plan of care–Addendum

HCN MONTHLY WEBINAR: How to Better Manage Physician Services in Hospice - October 16, 2019

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418.25 Admission to Hospice Care• “The hospice admits a patient only on the recommendation of the

medical director in consultation with, or with input from the patient's attending physician (if any).

• In reaching a decision to certify that the patient is terminally ill, the hospice medical director must consider the following information:–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.”

Medical Director• “418.102 (b) Standard: Initial Certification of terminal illness:

The medical director or physician designee reviews the clinical information for each patient and provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course.”

418.102(b)• “The physician must consider the following when making this

determination:–The primary terminal condition;–Related diagnosis(es), if any;–Current subjective and objective medical findings;–Current medication and treatment orders; and – Information about the medical management of any of the

patient's conditions unrelated to the terminal illness.”



Determination of Eligibility• Three parts:1. Eligible for the Medicare Hospice Benefit2. Seeking palliation to a terminal illness– Foregoing other aspects of the Medicare Benefit

3. Certified as terminally ill with a prognosis of less than 6 months– Art of “prognostication”• Def: the action of foretelling

future events

Determination of Eligibility• Prognostication:–Utilization of the Local Coverage Determinations (LCDs)–Combination of Comorbidities–Rapid Decline–Expert Opinion

Determination of Terminal Illness• Most contributing diagnosis to the patient’s terminal prognosis–According to ICD 10 guidelines

• All related and unrelated and unrelated diagnoses must appear in the plan of care and on the billing claim–Physician driven as to what is current and relevant to

patient’s care• Not just “coding”



Relatedness of Comorbidities• “…hospices are required to provide virtually all care…”–FY 2014 Hospice Wage Index and Payment Update

• “It is also the responsibility of the hospice physician to document why a patient’s need(s) would be unrelated to the terminal prognosis.”

NHPCO relatedness diagnosis

flow sheet

418.22 Certification of Terminal Illness• “418.22(b) Content of certification• (1)The certification must specify that the individual’s prognosis is

for a life expectancy of 6 months or less if the terminal illness runs its normal course.

• (2)Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. – Initially, the clinical information may be provided verbally, and

must be documented in the medical record and included as part of the hospice’s eligibility assessment.”



418.22 (b) Content of Certification• “ (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.– (iii) The narrative shall include a statement directly above 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/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”

418.22 (b) Content of Certification, cont’d– “(v) The narrative associated with the 3rd benefit period

recertification and every subsequent recertification must include an explanation of why the clinical findings of the face-to-face encounter support a life expectancy of 6 months or less.”

418.22 Continued• “418.22 (c) Sources of certification• For the initial 90-day period, the hospice must obtain written

certification statements (and oral certification statements if required) from:–The medical director of the hospice or the physician member

of the hospice interdisciplinary group; and–The individual’s attending physician if the individual has an

attending physician.–For subsequent periods, the only requirement is certification

by one of the physicians.”



Certification of Terminal Illness• Brief Narrative Statement–No checkboxes

• Supports the rationale of why a patient has a prognosis of less than 6 months

• Presume to be a direct communication to outside reviewer of the record as to why this patient is eligible

• Information used to determine the prognosis should be summarized in the narrative

Medication Coverage• Physician driven determination of what is:–Related–Unrelated–Not necessary

• “…hospices are required to provide virtually all care…”–FY 2014 Hospice Wage Index and Payment Update

• “It is also the responsibility of the hospice physician to document why a patient’s need(s) would be unrelated to the terminal prognosis.”

NHPCO medication flowsheet



New Admit Mrs. Jones• Review with hospice physician by “admitting” nurse– Physician determines prognosis less than 6 months, gives verbal

certification. Collaborates with attending physician.• Physician reviews medical record– Determination of relatedness– Documentation justifying if not related–Medication review, deprescribe, coverage, recommendations–Written Certification with brief narrative

• Patient is presented in IDG– Physician review of new issues since admission, updates to care,

follow up on deprescribing • All relayed to the Attending, if any

Interdisciplinary Group (IDG)• The IDG is the driver of the plan of care–Team approach with the physician as the leader•What distinguishes hospice from the remainder of the

medical world • IDG Meeting–Efficient use of the IDG’s time– Implementation of needs and

updates to the plan of care

IDG Meeting Opportunities• Review of admission –Drives documentation to appropriateness

• Ongoing relatedness review, deprescribing–Preparation for the addendum for non-covered services

• Ongoing evaluation of eligibility– LLOS & capturing important subtle changes– Live discharge preparation

• Driving the plan of care



Physician Definitions• Hospice Physician–Employee, contract, volunteer, under arrangement with hospice

• Non-hospice physician–No agreement with the hospice

• Attending physician or Attending of Record (AOR)– Is a doctor of medicine or osteopathy, nurse practitioner or

physician assistant– “Is identified by the individual, at the time he/she elects hospice

coverage, as having the most significant role in the determination and delivery of their medical care.”

• Medical Director–Only one medical director per hospice provider number

Physician Visits• Hospice can bill for medical services that are : –Related to the treatment and management of the patient’s

terminal illness AND–Are rendered by a physician who is either

employed or has contract with the hospice to provide these services AND• *If a nurse practitioner or physician assistant,

must be the AOR–Are medically necessary non-duplicative services

Physician Visits• Opportunity for: –Documentation to the prognosis of the patient–Capturing related and nonrelated diagnoses–Deprescribing– Justification for change in level of care–Education to staff –Reduce revocation for “aggressive care” and readmit– Live discharge reduction–Quality measures and daily visits at end of life–Financial benefit• Revenue and reduction in costs on non-necessary items



Payment Related Scrutiny• When we KNOW MORE, we DO MORE– Physician education on what this is, why important, what their role is– OIG emphasis on physician services• Does the narrative demonstrate eligibility?• Does the progress note demonstrate GIP level of care?• Is the physician reviewing the medical record?• Is the physician an active member of the IDG?

• Audits are a powerful opportunity and driver for improvement– Follow up on self improvement - documentation, services, engagement– Education to staff regarding results

• Involvement Opportunities–Medical director summary of care– Teleconference involvement

Barriers for the Hospice Physician• “Nurse Driven” culture• Unrealistic expectations– Lead IDG meeting and sign all recertifications, orders, death

certificates at the same time–Full time job in addition to hospice care–No previous experience in hospice and no new training–No oversight or follow up

• Lack of understanding of the regulatory requirement–Operating on internal processes

Opportunities for the Hospice Physician• Engage, engage, engage!• Knowledge is power–True understanding of the Medicare Hospice Benefit is

empowering in the physician role• Appropriate time allowance for role• Investing in the hospice physician is an

investment in your hospice



Thank You!

Questions?

Lauren Templeton, DO HMDCHospice Medical Director

For those watching in a group setting,log in or create an account on the webinar platform.

Click on the Webinars tab andscroll to the bottom.

Click on Evaluation and Certificates link and register.

Click View Product & Fill Out Evaluation.

Certificates are available only aftercompleting the evaluation.

The next HCN webinar is Wed, Nov 20 at 2pmET:“Emergency Preparedness in Hospice:

Are You Maintaining Readiness?”with Jennifer Kennedy of NHPCO

Next Quarterly Roundtable isTUESDAY Nov 26 at 3:30pmET



Documents

How to Better Manage Physician Services in Hospice · 418.25 Admission to Hospice Care • “The hospice admits a patient only on the recommendation of the medical director in consultation