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Gett ing i t R ight the F i rs t T ime
2017 Hospice Workshop Series
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
The information provided in this handout was current as of January 30, 2017. Any changes or new information superseding the information in this handout will be provided in articles and publications with publication dates after January 30, 2017, posted at www.PalmettoGBA.com/hhh.
Disclaimer
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Palmetto GBA - Medicare Administrative Contractor (MAC) January 2017
Part 1 3
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Data Analysis
Length of Stay (LOS)
Screening New Patients for Hospice
Interdisciplinary Group (IDG) Member Roles
Medical Director
Nurse
Social Worker
Pastoral Counselor
Medical Review Program
Medical Review Top Denials
Dementia Patients
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Agenda
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Data Analysis 5
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Congressional Budget Office, Updated Budget Projections 2016 (March 2016)
Medicare as a Share of the Federal Budget 2015
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Congressional Budget Office, 2016 Medicare Baseline (March 2016)
Medicare Benefit Payments by TOS, 2015
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
CGS Administrators: Colorado, Delaware, Washington, DC, Iowa, Kansas, Maryland, Missouri, Montana, Nebraska, North Dakota, Pennsylvania, South Dakota, Utah, Virginia, West Virginia, and Wyoming
National Government Services (NGS): Alaska, Arizona, California, Connecticut, Hawaii, Idaho, Maine, Massachusetts, Michigan, Minnesota, Nevada, New Hampshire, New Jersey, New York, Oregon, Puerto Rico, Rhode Island, Vermont Virgin Islands, Washington, and Wisconsin
Palmetto GBA: Alabama, Arkansas, Florida, Georgia, Indiana, Illinois, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee, and Texas
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Hospice Across the Nation
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110
39
42
191
115 88
24
135
98
78
37
135
122 89
57
486
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Number of Hospice Providers April - September 2016
JM total – 1,929 Outside of 16 states - 87
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Beneficiaries with Multiple Providers April – September 2016
19.5
6.9
7.6
16.7
6.0 7.3
3.0
12.7
18.9
6.5
10.7
6.6
13.4 19.1
7.0
14.7
JM total – 10.1
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Number of Hospice Beneficiaries April – September 2016
JM Total – 459,132
19,959
9,920
81,958
29,325
29,766 18,977
11,010
14,653
10,404
29,247
6,143
41,072
12,544 17,748
20,169
72,699
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
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Number of Claims April – September 2016
60,768
23,226
210,637
82,505
70,068 47,016
23,408
41,302
29,200
73,625
17,162
104,897
35,783 50,169
51,141
209,794
JM total – 1,218,784
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10,160
7,710
10,428
10,144
8,470 8,470
6,992
9,584
9,294
8,990
10,155
9,229
9,389 9,940
8,217
10,351
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Disbursem*nt Per Beneficiary April – September 2016
JM total – 9,662
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
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NCLOS April – September 2016
.26
.18
.23
.26
.18 .19
.13
.26
.24
.21
.22
.26 .24
.20
.28
.26
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Aggregate LOS April – September 2016
156.1
104.0
130.9
145.8
99.5 107.9
74.3
149.8
143.4
115.4
138.6
124.8
151.4 140.7
115.8
159.2
JM total – 132 days
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Overview Category
Number of Claims Current
Number of Beneficiaries
Current
Number of Providers Current
651 Hospice/Routine Home Care 2,173,735 591,069 1,944
656 Hospice/General Inpatient Care 208,198 175,232 1,323
652 Hospice/Continuous Home Care 60,666 49,639 718
657 Hospice/Physician Services 243,761 161,393 584
655 Hospice/Inpatient Respite Care 43,838 28,700 1,485
659 Hospice/Other 109 74 25
650 Hospice Services/General 7 7 6
Hospice Drill Down
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Are you admit t ing the r ight pat ient?
Palmetto GBA - Medicare Administrative Contractor (MAC) January 2017
Screening New Patients for Hospice
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Hospice care is appropriate when a beneficiary has a terminal illness with a life-expectancy of 6 months or less
A beneficiary is ready for hospice when they have decided to pursue treatments meant only to promote comfort, not cure the illness
Effective documentation of the terminal prognosis begins with a good screening process
When is it Time for Hospice?
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Does the referring source foresee the person’s life expectancy to be 6 months or less?
What did they base the referral on?
Is the referral source familiar with LCDs?
Has something changed recently?
How does the patient compare today to 6 months ago? 12 months ago?
Gather the Facts
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Admitting diagnosis
Current medical findings
Orders for medications and treatments
Family and patient’s awareness of disease and prognosis
Significant patient and family information/history
History and physical
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What You Need to Know
Hospice Care: A Physician's Guide. Michigan Hospice and Palliative Care Organization 2006
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Ambulation
Continence
Transfer
Dressing
Feeding
Bathing
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Activity Limitations
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
COPD
CHF
Ischemic heart disease
Diabetes mellitus
Neurologic disease
Renal failure
Liver disease
Neoplasia
AIDS/HIV
Dementia
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Co-Morbidities
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Weight loss (≥10% body weight in prior 6 months)
↓ anthropomorphic measurements (e.g., mid-
arm circumference, abdominal girth)
Observation of ill-fitting clothes, ↓ in skin
turgor, ↑ skin folds
↓ serum albumin or cholesterol
Dysphagia leading to recurrent aspiration and/or inadequate oral intake
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Other Symptoms
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Change in functional status
Decline in Palliative Performance Score (PPS)
Progressive decline in Functional Assessment Staging (FAST) for dementia (from 7A on the FAST)
Progressive stage 3-4 pressure ulcers
History of increasing ER visits
Hospitalizations or physician visits related to the hospice primary diagnosis prior to election of hospice
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Other Conditions
http://washington.providence.org/in-home-services/soundhomecare-and-hospice/for-healthcare-professionals/~/media/930F9FDFD6CC4277B802EB3E0D720617.pdf/
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PPS Scale
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
100-70% PPS
Patient/family need for hope/understanding of disease
Patient/family education re: disease management, medications, personal care, nutrition, symptom crisis/distress management plan
Referrals to optimize functioning
Psychosocial assessment
Spiritual assessment - cultural/religious resources
Stable
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60-40% PPS
Most difficult for patients - impacts on all spheres of life (need for holistic, patient and family-centered care)
Requires greatest amount of nursing care
Increasing care and educational needs
Transitional
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
<30% PPS
Review medications/routes of administration, need for further investigations/lab tests/clinic visits
Determine main contact in the community - family physician, homecare, palliative care physician
Pain/symptom management
Prepare family for death - what do they expect, what are their past experiences with death
Ensure affairs are in order - e.g. POA, wills, custody arrangements for children, etc.
End of Life
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
The PPS score is determined by reading horizontally at each level to find the “best fit” for the patient
Leftward columns are “stronger” determinants, thereby taking precedence over others
Begin at the left column until the appropriate ambulation level is found
Read across to the next column until the correct activity/evidence of disease is located
Read across to the self-care column, intake and conscious level columns before assigning the PPS score to the patient
How to Use the PPS
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Only use the PPS in 10% increments (e.g., cannot score 45%)
Sometimes 1 or 2 columns seem easily placed at 1 level, but 1 or 2 columns seem better at higher or lower levels
In these cases, use your clinical judgment and the leftward dominance rule to determine a more accurate score the patient
Making “Best Fit” Decisions
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The patient spends the majority of the day sitting in bed or lying down due to fatigue from advanced disease
She requires considerable assistance to walk even short distances
She is fully conscious
She has good nutritional intake
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Example Case Study #1
Victoria Hospice Society
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
The patient is very weak and remains in a chair a couple of hours a day
The rest of the time, he is in bed
He has advanced disease and is requiring almost complete assistance with self-care and feeding
He is experiencing decreased food intake, with a few small snacks that remain mostly unfinished
He has adequate fluid intake
The patient is drowsy but not confused
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Example Case Study #2
Victoria Hospice Society
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The patient is up and about on her own.
She has experienced a recent recurrence of the disease
She can do household chores with adequate rest periods
The patient requires occasional assistance with self-care whereby her caregiver watches her get in and out of the shower
Her intake is reduced from normal but still adequate
The patient is fully conscious with no confusion
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Example Case Study #3
Victoria Hospice Society
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Mr. Jones is a 58 year old man with metastatic prostate cancer
He is retired and leads an active life driving to his doctor’s appointments, playing golf three times a week with this buddies, and gardening with his wife of 30 years
He has noticed over the last year that he now needs to use a golf cart to complete his 18 holes
In the past, he was able to carry his own clubs and walk the course without effort
He is able to complete all of his activities of daily living without assistance
He has noticed he doesn’t quite have the appetite he once did, requiring smaller more frequent meals due to early satiety, but has not lost any weight in the past 6 months so he is unconcerned about his appetite
He is fully alert and oriented to person, place and time
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Example Case Study #4
References for this Activity. Johnston, M., & Mattar, L. (2006). Introduction to the Palliative Care Performance Scale (v. 2): A tool for understanding transitions at the end of life.
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Mrs. Edith Smith is a 67 year old woman with metastatic breast cancer
She has recently developed a pleural effusion that is causing her severe shortness of breath making it difficult to ambulate even within her small apartment
Most days she sits in her lazy boy chair watching TV
Once a great knitter, she is too weak to finish the sweater she is knitting for her granddaughter
Recently homecare has begun providing services to help her with her Activities of Daily Living (ADLs) such as bathing and dressing
Her two children who live close by check in on her each day and deliver her meals, but they noticed that she is eating only about half of the meals they are providing to her
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Example Case Study #5
References for this Activity. Johnston, M., & Mattar, L. (2006). Introduction to the Palliative Care Performance Scale (v. 2): A tool for understanding transitions at the end of life.
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Mr. Ennoch Birchstick is a 32 year old man with AML
Despite aggressive chemotherapy, his disease has not gone into remission
He lives with his wife and two young children
They have remade their living room into a room for Ennoch because he is unable to ambulate to the bedroom he shares with his wife, and he would like to be part of the day to day household activities even if he is unable to actively participate
For the past week, Ennoch has been totally bed bound, requiring total care for all of his ADLs
While he still enjoys the food his family prepares, he is only able to eat a few bites
Mainly, he drinks Ensure throughout the day to maintain his nutrition
He is usually fully alert and oriented but is sleeping more during the day
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Example Case Study #6
References for this Activity. Johnston, M., & Mattar, L. (2006). Introduction to the Palliative Care Performance Scale (v. 2): A tool for understanding transitions at the end of life.
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Interdisciplinary Group (IDG) Member Roles
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Doctor of Medicine or Osteopathy
Registered Nurse
Social Worker
Pastoral or Other Counselor
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Members of the IDG
42 CFR 418.68 The Medicare Conditions of Participation for Hospice Care
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Participation in the establishment of the POC
Provision or supervision of hospice care and services
Periodic review and updating of the POC for each individual receiving hospice care
Establishment of policies governing the day to day provision of hospice care and services
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Role of IDG
42 CFR 418.68 The Medicare Conditions of Participation for Hospice Care
The Medical Director is a Doctor of Medicine or Osteopathy who assumes overall responsibility for the medical component of the hospice’s patient care program
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Medical Director
42 CFR 418.54 The Medicare Conditions of Participation for Hospice Care
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Consults with the attending physician
Reviews patient eligibility for hospice services
Acts as a medical resource for the IDG
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Medical Director Responsibilities
The hospice must provide nursing care and services by or under the supervision of a registered nurse
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Nursing Services
42 CFR 418.82 The Medicare Conditions of Participation for Hospice Care
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Nursing services must be directed and staffed to assure that the nursing needs of patients are met
Patient care responsibilities of nursing personnel must be specified
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Nursing Services
42 CFR 418.82 The Medicare Conditions of Participation for Hospice Care
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Vague documentation
Patient having dyspnea on exertion
Detailed documentation
Patient ambulates 10 feet between chair & bed before experiencing dyspnea and weakness; with 1 assist. One month ago, patient ambulated slowly from room to room with walker. Family reports that the patient is only able to sit up with family for 30 minutes before returning to bed.
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Documentation Example 1
http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=11&ved=0ahUKEwit443LwJHPAhWMPD4KHawXDvs4ChAWCCIwAA&url=http%3A%2F%2Fmoodle.hospiceofmarion.com%2Fpluginfile.php%2F7594%2Fmod_folder%2Fcontent%2F0%2FDocumentation%2Fstrengthening%2520hospice%2520doc%2520handouts.pdf%3Fforcedownload%3D1&usg=AFQjCNHJjdkpEicO416jYcvGTuzzhlLBZg&bvm=bv.132479545,d.cWw
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Vague documentation
Patient having dyspnea on exertion
Better documentation
Observed patient communicating only 2-3 words without shortness of breath, previously was able to talk 10-15 minutes during last week (2 weeks ago). Patient tries to use a communication board with occasional frustration.
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Documentation Example 2
http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=11&ved=0ahUKEwit443LwJHPAhWMPD4KH
awXDvs4ChAWCCIwAA&url=http%3A%2F%2Fmoodle.hospiceofmarion.com%2Fpluginfile.php%2F7594%2Fmod_fold
er%2Fcontent%2F0%2FDocumentation%2Fstrengthening%2520hospice%2520doc%2520handouts.pdf%3Fforcedownl
oad%3D1&usg=AFQjCNHJjdkpEicO416jYcvGTuzzhlLBZg&bvm=bv.132479545,d.cWw
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Vague documentation
Patient is eating less, appetite declining
Better documentation
Appetite declined from eating 50% of a sandwich 1 month ago, now eating 2-3 bites at a meal. Family is concerned that the patient refuses his favorite meal.
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Documentation Example 3
http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=11&ved=0ahUKEwit443LwJHPAhWMPD4KH
awXDvs4ChAWCCIwAA&url=http%3A%2F%2Fmoodle.hospiceofmarion.com%2Fpluginfile.php%2F7594%2Fmod_fold
er%2Fcontent%2F0%2FDocumentation%2Fstrengthening%2520hospice%2520doc%2520handouts.pdf%3Fforcedownl
oad%3D1&usg=AFQjCNHJjdkpEicO416jYcvGTuzzhlLBZg&bvm=bv.132479545,d.cWw
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Medical social services must be provided by a qualified social worker, under the direction of a physician
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
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Medical Social Services
42 CFR 418.84 The Medicare Conditions of Participation for Hospice Care
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Assessment of the social and emotional factors related to the beneficiary's need for care, response to treatment and adjustment to care
Assessment of the relationship of the patient’s medical and nursing requirements to the patient’s home situation, financial resources and availability of community resources
Appropriate action to obtain available community resources to assist in resolving the patient’s problem
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Medical Social Services
CMS Manual System, Pub 100-02, Medicare Benefit Policy, Chapter 9, Section 40.1.2
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Areas for consideration in the comprehensive assessment include
Relevant past and current health situation (including the impact of problems such as pain, depression, anxiety, delirium, decreased mobility)
Family structure and roles
Patterns/style of communication and decision making in the family
Social Work Assessment
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Stage in the life cycle, relevant developmental issues
Spirituality/faith
Cultural values and beliefs
Client's/family's language preference and available translation services
Client's/family's goals in palliative and end of life treatment
Social Work Assessment
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Social supports, including support systems, informal and formal caregivers involved, resources available, and barriers to access
Past experience with illness, disability, death, and loss
Mental health functioning including history, coping style, crisis management skills
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Social Work Assessment
NASW Standards for Social Work Practice in Palliative and End of Life Care ©2007 National Association of Social Workers.
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Tell me about your family member
What do you understand about your family member’s illness?
Given what we know about your family member’s illness, what are your hopes?
Given what we know about your family member’s illness, what worries you most?
Where do you find your strength?
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5 Questions Model
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Quality of life
Baseline function/ADLs
Ideas to improve hospital quality of life
Living situation/family composition
What is important to child and family
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Tell Me About Your Family Member
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Family’s understanding of disease process/illness trajectory
Family’s state of processing/coping
Family’s education/cognition level
Which providers/services does family identify with rely on for information
What do You Understand About Your Family Member’s Illness?
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Family’s understanding of disease process/illness trajectory
Family’s priorities/goals of care
Align with family/build rapport
Intervention plan/strategy
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What Are Your Hopes?
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Family’s understanding of disease process/illness trajectory
Family’s priorities/goals of care
Identification of distressing symptoms
Align with family/build rapport
Intervention plan/strategy
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What Worries You Most?
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Religious/spiritual preferences
Sources of family support/resources
Family’s relationship with medical providers
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Where do You Find Your Strength?
THE POWER OF SOCIAL WORK DOCUMENTATION From Burden to Effective Palliative Care Intervention Danielle Jonas, MSW, Marsha Joselow, MSW LICSW, Nick Purol, MSW LICSW
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Reason for Consult
Participants
Family Composition
Coping and Support
Cultural/Spiritual Formulation
Communication and Decision-Making
Hopes/Goals
Worries/Suffering
Clinical Impressions
Plan
Giving the Note Shape: Example Documentation
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The Social Work Assessment Tool was developed by the Social Work Outcomes Task Force of the Social Work Section, National Hospice and Palliative Care Organization, National Council of Hospice and Palliative Professionals
“Pastoral Counseling is a unique and challenging career. Individuals must develop and maintain skills in two distinct areas – counseling and ministry. It is a major challenge to maintain professional competence in these two unique fields. This dedication to service speaks highly of those who choose to walk this path…..”
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
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Pastoral Counseling
The National Board for Certified Pastoral Counselors
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
What are the patient’s issues related to life, faith, illness, dying, and death?
What needs or concerns were expressed or observed?
Recording unique cultural or religious preferences associated with the end-of-life. Was this communicated to the IDG?
Guidelines for Chaplain Documentation
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Record the story that tells
Who is this patient? Family?
Significant relationships? Dynamics?
Coping styles?
Religious preferences? Its meaning?
Spiritual perspectives? Its meaning?
Beliefs, thoughts, feelings toward afterlife?
Views of the future?
What the patient/family wants in the days ahead?
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Guidelines for Chaplain Documentation
PowerPoint Chaplain Documentation: Recording Spiritual Care in a Clinical World. 2005. Rodney Bolejack, D. Min. Chaplain
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Pt. expressed moderate spiritual, emotional and relational distress re: feeling abandoned/punished by God through his illness and neglected by his faith community while hospitalized. (needs)
Pt. reported strong support from his wife of 30 years. However, he stated “we don’t talk about God stuff.” His two adult children live out of state. He identified no intimate friendships. (needs & resources)
Pt. expressed intermediate hope he will be well enough to attend his daughter’s wedding in June. Pt. expressed little sense of ultimate hope at present. (hopes)
Pt. self-identified as an “old philosopher” and seems willing and able to explore issues as long as his pain is controlled. (resources)
Pt. is receptive to and would benefit from continued chaplaincy care to address providence, theodicy, grief, hope & reconciliation. (needs & resources)
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Assessment: An Example Based on Needs/Hopes/Resources Model
Brent Peery, “Chaplaincy Assessment –Perceptive Caring”, Association of Professional Chaplains Webinar, January 23, 2013
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
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Directed
Encouraged
Identified
Explored
Facilitated
Validated
Reframed
Normalized
Educated
Modeled
Provided spiritual guidance
Provided spiritual reading _________
Engaged in life review
Sang/played/listened to hymns
Intervention Words and Phrases
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Arthur M. Lucas MDiv and BCC . Introduction to The Discipline for Pastoral Care Giving Journal of Health Care Chaplaincy Volume 10, 2000 - Issue 2
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
CH made routine visit (purpose) for spiritual and emotional support of pt. (goal)
Patient has hospice Dx of COPD. (note diagnosis)
CH spoke with charge nurse Lisa and reviewed pt.'s chart to ensure continuity of care. (coordination of care)
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Routine Visit Narrative Documentation Example
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Upon arrival, pt. lying on back in bed, slightly inclined, with 02 on. Pt. said, “I stay in bed because I’m so tired all the time.” Pt. was up in wheelchair at previous visit 2 weeks ago. Pt. reported discomfort related to increased swelling in legs. (symptoms and decline related to diagnosis)
CH notified NF charge nurse Lisa, as well as hospice RN case manager, about pt.'s report of discomfort. (coordination of care)
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Routine Visit Narrative Documentation Example
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Pt. reported feeling anxious about family’s well-being after pt.'s death. CH provided active listening and validation of feelings for emotional support. (needs and interventions)
Per pt. request, and based on POC, CH facilitated prayers with pt. for spiritual support. (need and intervention)
Upon CH’s offer, pt. requested that CH provide communion for pt. at next visit. (need)
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Routine Visit Narrative Documentation Example
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Pt. appeared comfortable and peaceful at end of visit AEB saying, “I feel so much better after your visits,” and expressing no verbal complaints or non-verbal sx of pain/discomfort. (outcomes)
CH to provide communion for pt. at next visit, and continue POC of 1-2 visits per month + 1 PRN visit for support. (summary of planned interventions)
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Routine Visit Narrative Documentation Example
Powerpoint presentation: Documenting to Dazzle” Greg Volpitto, MDiv Support Services Director, Crossroads Hospice Chaplain Core Curriculum Track 2 Seminar April 17, 2015
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
All team members are involved in spiritual assessment
All team members listen, utilize visual cues, and ask about patient and family spiritual/religious practices, frameworks, and needs
The chaplain or social worker often takes the lead
The chaplain or social worker customarily conduct an in-depth assessment at the start of care and develop a plan of spiritual care directed by patient and family goals meditation, or prayer help relieve pain. “Are any of these something you would find helpful?”
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Basic Skills and Techniques in Providing Spiritual Care Assessment
http://endlink.lurie.northwestern.edu
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Helpful assessment strategies include
Asking open-ended questions
“Is there anything you are hoping for during this time?”
“Where do you turn for strength?”
Providing options
“Some persons find that music, meditation, or prayer help relieve pain. Are any of these something you would find helpful?”
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Basic Skills and Techniques in Providing Spiritual Care
http://endlink.lurie.northwestern.edu
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Ongoing assessment is crucial
As the patient’s health status changes
As new symptoms arise or are not relieved
If the dying process is prolonged
When death draws near
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Basic Skills and Techniques in Providing Spiritual Care
http://endlink.lurie.northwestern.edu
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Progressiv e Correct ive Act ion (PCA)
Medical Review Program
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
The Medical Review program is designed to promote a structured approach in the interpretation and implementation of Medicare policy
74
Medicare Medical Review Program
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Includes
Data analysis
Medical review of claims
Provider education and feedback
75
PCA Process
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Based on a specific service (code)
An article is posted on the Palmetto GBA website to notify the providers
Random sampling among all providers billing the service in question
100 total claims for the initial probe are selected for review from the specific state(s)
Notify the provider community of the results by way of a website article
Service-Specific
76
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Provider is notified via individual letter
A predetermined percentage of claims billed will be selected for medical review every time the provider bills
Sampling of up to 40 claims for the initial probe
Provider notified of results via individual letter after claims are reviewed and processed
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Provider-Specific
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
A percentage of claims is selected after services are rendered and billed
An edit is established through the claims processing system
Requests are generated and medical records are reviewed before claim processing is completed
If the medical records meets the requirements, the claim is paid
78
Pre-Pay Review
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Involves claims that have previously paid through the processing system
When a determination results in a denial of services, the claims will be adjusted or an overpayment letter is sent to recover the overpayment amount
Written notification of the results is sent to the provider upon completion of the review
79
Post-Pay Review
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Service-Specific Provider-Specific
Pre-pay Service-Specific Pre-pay
Provider-Specific
Pre-pay
Post-pay Provider-Specific
Post-pay
80
Type of Review
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Medical review data analysis for the reviewed and processed claims is expressed as a Charge Denial Rate (CDR)
The CDR will determine whether the medical review will be continued or discontinued
Data Analysis of Review Results
81
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Total $ denied for the claims reviewed
Total $ for the claims reviewed and processed
Multiplied by 100 = CDR
82
CDR
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Minor
Moderate
Major
83
PCA Decision Criteria
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
84
Minor
CDR = 0% - 33%
• Education provided
• Potential follow-up sample review if warranted by trending or data analysis
• Potentially removed from edit
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
85
Moderate
CDR = 34% - 66%
• Education provided
• Initiate a Targeted Medical Review
• May request CAP
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
86
Major
• Education provided
• Initiate a Targeted Medical Review edit
• Request CAP
CDR = 67% - 100%
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Palmetto GBA - Medicare Administrative Contractor (MAC) January 2017
Medical Review Top Denials 87
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Denial
Code
Denial
Code
Description
Claims
Denied
Percent of Claims Denied to
Total Claims Denied
56900
Auto Denial - Requested Records not
Submitted 191 86.0
55503 LCD Denial - no medical necessity 11 5.0
5CF01
General Inpatient Services Not Reasonable
and Necessary - Beneficiary Liable 7 3.2
5CFNP No Plan of Care Submitted 5 2.3
5CF36 Not Hospice Appropriate 3 1.4
5CFH4 Initial Certification Not Signed 2 0.9
5CF91
Hospice GIP Reduction - Services Not
Reasonable/Necessary 1 0.5
5CFH6 Initial Certification Not Timely 1 0.5
5FFH6 Initial Certification Not Timely 1 0.5
Medical Review Top Denials
88
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
5FFH2 No certification present
5FFH3 No certification for dates billed
5FFH4 Initial certification not signed
5FFH5 Subsequent certification not signed
5FFH6 Initial certification not timely
5FFH7 Subsequent certification not timely
5FFH8 No prognosis statement
5FFH9 Physician narrative statement not present or not valid
89
Certification Denials
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
The narrative must reflect the patient’s individual clinical circ*mstances
The narrative must not contain check boxes or standard language used for all patients
Include a statement indicating 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, examination of the patient
90
Narrative Requirements
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Beneficiary name
6 month prognosis statement
Diagnosis
Reference benefit period
Documentation accompanying certification to support why the patient is certified terminally ill
Dated physician signature(s)
91
Elements of a Physician Certification
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
5FFNP – No plan of care submitted
5FFIP - Invalid plan of care submitted
92
POC Denials
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
5FF36 – Documentation does not support the terminal prognosis
93
Hospice Appropriateness Denial
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
94
Admitted for end stage cardiac disease
Powerpoint. Ensuring Clinical Documentation Reflects Care and Meets Requirements. National Hospice and Palliative Care Organization, 2010
Paint the Picture
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
95
Admitted for end stage cardiac disease
Poor response to standard treatment
Desires palliative care
Powerpoint. Ensuring Clinical Documentation Reflects Care and Meets Requirements. National Hospice and Palliative Care Organization, 2010
Paint the Picture
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
96
Admitted for end stage cardiac disease
Poor response to standard treatment
Desires palliative care
Is NYHA Class IV with significant symptoms of angina at rest & inability to carry on any physical activity w/o discomfort
Ejection fraction of ≤20%, significant ventricular arrhythmias, & unexplained syncope episodes
Powerpoint. Ensuring Clinical Documentation Reflects Care and Meets Requirements. National Hospice and Palliative Care Organization, 2010
Paint the Picture
1/23/2017
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
56900 - Requested medical records were not received within the 45 day time limit
97
Not Responding to a Request for Medical Records Denial
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Signed Notice of Election
Signed physician’s certification to cover the dates of service billed
Statement when the hospice medical director is the attending physician
POC pertinent to the dates of service billed
98
Responding to Hospice Documentation Requests
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Documentation to substantiate terminality and medical necessity
Documentation as required in the LCD
99
Responding to Hospice Documentation Requests
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
If continuous care is billed, include
Notes for all hours that care is rendered
Who rendered services (nurse or aide)
Documentation of when the continuous care began and ended
100
Responding to Hospice Documentation Requests
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Ensure
Documentation is for the beneficiary and dates of service indicated on the request
Copies are legible, not too light, too dark or blurred
No portion of the page has been cut off or omitted
101
Responding to Hospice Documentation Requests
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
If documentation includes 2-sided forms, submit both sides
Compare copied medical records to original medical records
Suggestions
Number the pages
Keep second copy
102
Responding to Hospice Documentation Requests
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End of L i fe Dement ia
Dementia Patients 103
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Copyright © 2009 The research Foundation of State University of New York http://www.textmap.com
http://www.textmed.com/heatmaps/disease/dementia-us-heatmap.gif
104
Dementia Statistics
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Semin Reprod m\Med ©2009 Thieme Medical Publishers
105
Types of Dementia by Percentage
Young Onset Dementia Dementia Occurring Later in Life
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
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Distribution of Diagnoses
Sampson E L, Warren J D and Rossor Post Med J 2004; 80: 125-139.
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Dementia is a broad term that describes a set of symptoms that develop as a result of damage to the brain
Dementia is progressive and irreversible, and there is no cure for the condition
107
What is Dementia?
http://www.standard.co.uk/lifestyle/health/what-is-dementia-5-ways-to-recongnise-the-signs-and-symptoms-a3337161.html
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Communication
Memory loss
Loss of mobility
Eating and weight loss
Problems with continence
Unusual behavior
108
Symptoms
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Problems with communication are a feature of the later stages of dementia
The person will generally have limited or no speech
They will also have reduced ability to understand what is being said to them
Relying only on verbal communication can lead to difficulties understanding what the person is trying to communicate, possibly missing basic needs such as pain, hunger and thirst
109
Communication
© Copyright 1998-2016 Alzheimer's Society
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Memory loss is likely to be very severe in the later stages of dementia
People may be unable to recognize those close to them or even their own reflection
They may no longer be able to find their way around familiar surroundings or identify everyday objects
However, they may occasionally experience sudden flashes of recognition
The person may believe that they are living in a time from their past, and may search for someone or something from that time
110
Memory Loss
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Many people with dementia gradually lose their ability to walk and to perform everyday tasks unaided
One of the first signs of this is that they shuffle or walk unsteadily
They may also seem slow or clumsy and be more likely to bump into things, drop objects or fall
Some people with dementia eventually become confined to a bed or chair
111
Loss of Mobility
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Most people with dementia lose weight in the later stages of the illness, although occasionally people eat too much and put on weight
Weight loss can affect the immune system, making it harder for the person to fight infections
112
Eating and Weight Loss
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Many people lose control of their bladder in the later stages of dementia. Some also lose control of their bowels
This may happen all or most of the time, or may just be a case of occasional leakage
Incontinence is not an inevitable symptom of dementia, but there are a number of reasons why someone with dementia could become incontinent. These include various medical conditions, a number of which are treatable
113
Problems with Continence
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Possible causes include
Urinary tract infection
Severe constipation
Side-effects of medication
Prostate gland trouble
Forgetting to go to the toilet or forgetting where the toilet is
Not recognizing the need to go to the toilet
114
Problems with Continence
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
People in the later stages of dementia sometimes behave in ways that others find unusual or puzzling
The person may react aggressively if they feel threatened or cannot understand what is going on around them
The person may rock backwards and forwards, use repetitive movements or keep calling out the same sound or word
115
Unusual Behavior
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Some people experience hallucinations, in which they see, smell, hear, taste or feel things that are not really there
Others develop delusions, in which they experience distorted ideas about what is happening
Excessive hand activity becomes more common
The person may constantly wring their hands, pull at their clothes, tap or fidget, or touch themselves inappropriately in public
The person may have long periods of physical inactivity where they remain still, with their eyes open but not engaged in any other activity
116
Unusual Behavior
Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes Phase 3 End-of-Life Care© 2007 Alzheimer's Association. All rights reserved
1/23/2017
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Alzheimer’s Disease
Vascular Dementia
Lewy Body Dementia
Frontotemporal Dementia
117
Types of Dementia
A manual for good social work practice Supporting adults who have dementia© Crown copyright 2015 2904417 Produced by Williams Lea for the Department of Health
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
http://www.familyhealthonline.ca/fho/familymedicine/FM_stroke_FHc13.asp
118
Anatomy of the Brain
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Hospice Alzheimer's Disease & Related Disorders (L34567)
119
Alzheimer’s Disease LCD
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Projected Number with Alzheimer’s (in thousands)
State 2016 2025 % Change
Alabama 89 110 23.6
Arkansas 54 67 24.1
Florida 510 720 41.2
Georgia 130 190 46.2
Illinois 220 260 18.2
Indiana 110 130 18.2
Kentucky 69 86 24.6
Louisiana 84 110 31.0
120
Alzheimer’s Statistics
Weuve J, Hebert LE, Scherr PA, Evans DA. Prevalence of Alzheimer disease in U.S. states. Epidemiology 2015;26(1):e4-6
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Projected Number with Alzheimer’s (in thousands)
State 2016 2025 % Change
Mississippi 52 65 25.0
New Mexico 37 53 43.2
North Carolina 160 210 31.3
Ohio 210 250 19.0
Oklahoma 62 84 35.5
South Carolina 84 120 42.9
Tennessee 110 140 27.3
Texas 350 490 40.0
121
Alzheimer’s Statistics
Weuve J, Hebert LE, Scherr PA, Evans DA. Prevalence of Alzheimer disease in U.S. states. Epidemiology 2015;26(1):e4-6
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Number of Deaths and Mortality Rates per 100,000 due to Alzheimer’s 2013
State Number of deaths Mortality rates
Alabama 1,398 28.9
Arkansas 918 31.0
Florida 5,093 26.0
Georgia 2,048 20.5
Illinois 2,919 22.7
Indiana 2,104 32.0
Kentucky 1,462 33.3
Louisiana 1,505 32.5
122
Alzheimer’s Statistics
Xu JQ, Murphy SL, Kochanek KD, Bastian BA. Deaths: Final data for 2013. National vital statistics reports; vol 64 no 2. Hyattsville, MD: National Center for Health Statistics. 2016.Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf. Accessed March 4, 2016.
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Number of Deaths and Mortality Rates per 100,000 due to Alzheimer’s 2013
State Number of deaths Mortality rates
Mississippi 925 30.9
New Mexico 339 16.3
North Carolina 2,872 29.2
Ohio 3,798 32.8
Oklahoma 1,145 29.7
South Carolina 1,623 34.0
Tennessee 2,536 20.0
Texas 5,293 20.0
123
Alzheimer’s Statistics
Xu JQ, Murphy SL, Kochanek KD, Bastian BA. Deaths: Final data for 2013. National vital statistics reports; vol 64 no 2.
Hyattsville, MD: National Center for Health Statistics. 2016. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf Accessed March 4, 2016.
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Hebert LE, Weuve J, Scherr PA, Evans DA. Alzheimer Disease in the United States (2010-2050) estimated using the 2010 Census. Neurology 2013;80(19):1778-83.
124
Ages of People with Alzheimer's in the US
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Alzheimer's Association. 2012 Alzheimer's Disease facts and figures. Alzheimer's and Dementia: The Journal of the Alzheimer's Association. March 2012; 8:131–168
125
Projected Changes Between 2000 and 2025 in Alzheimer's Disease Prevalence by State
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
http://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_04.pdf
126
Alzheimer’s Disease Mortality by State
The number of deaths per 100,000 total population
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18.5
17.9
15.3
20.7
17.2 16.8
14.2
18.7
19.4
16.9
15.2
16.3
18.9 19.7
18.1
23.0
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
127
% Beneficiaries with Alzheimer’s April – September 2016
JM Total – 18.1
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
In 2016, total payments for health care, long-term care and hospice are estimated to be $236 billion for people with Alzheimer's and other dementias, with just under half of the costs borne by Medicare
Medicare and Medicaid are expected to cover $160 billion, or 68 percent, of the total health care and long-term care payments for people with Alzheimer's disease and other dementias
128
Cost to Nation
http://www.alz.org/facts/
1/23/2017
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
In the final stage of this disease, individuals lose the ability to respond to their environment, to carry on a conversation and, eventually, to control movement
They may still say words or phrases, but communicating pain becomes difficult
As memory and cognitive skills continue to worsen, personality changes may take place and individuals need extensive help with daily activities
129
Severe Alzheimer's Disease (Late-Stage)
http://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Require full-time, around-the-clock assistance with daily personal care
Lose awareness of recent experiences as well as of their surroundings
Require high levels of assistance with daily activities and personal care
Experience changes in physical abilities, including the ability to walk, sit and, eventually swallow
Have increasing difficulty communicating
Become vulnerable to infections, especially pneumonia
130
Severe Alzheimer's Disease (Late-Stage)
http://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp
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FUNCTIONAL STAGES IN NORMAL HUMAN DEVELOPMENT AND ALZHEIMER’S DISEASE © by Dr. Barry Reisberg © 1984, 1986, 1996 All rights reserved. FAST Stages 3 - 7
APPROXIMATE AGE ACQUIRED ABILITIES LOST ABILITIES ALZHEIMER STAGE
12+ years Hold a job Hold a job 3 - INCIPIENT
8 - 12 Years Handle simple finances Handle simple finances
4 - MILD
5 - 7 Years Select proper clothing Select proper clothing
5 - MODERATE
5 years Put on clothes unaided Put on clothes unaided
6 – MODERATELY SEVERE
4 Years Shower unaided Toilet unaided
Shower unaided Toilet unaided
"
3 - 4.5 Years Control urine Control Urine "
2 - 3 Years Control Bowels Control Bowels "
15 Months Speak 5 - 6 words Speak 5 - 6 words 7 - SEVERE
1 Year Speak 1 word Walk
Speak 1 word Walk
-
6 - 10 Months Sit up Sit up "
2 - 4 Months Smile Smile "
1 -3 Months Hold up head Hold up head
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC) 131
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Frontotemporal dementia (FTD) is the clinical presentation of frontotemporal lobar degeneration, which is characterized by progressive neuronal loss predominantly involving the frontal and/or temporal lobes, and typical loss of over 70% of spindle neurons, while other neuron types remain intact
132
Frontotemporal Dementia
Brain Cells for Socializing". Smithsonian. Retrieved 30 October 2015.
1/23/2017
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
http://www.brightfocus.org/sites/default/files/styles/full_width/public/frontotemporal-dementia3.jpg?itok=eWYXIg1c
133
FTD
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
http://medschool.ucsf.edu/sites/medschool.ucsf.edu/files/ADvsFTD_450x350.jpg
134
Alzheimer’s vs FTD
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Frontotemporal dementia or FTD (sometimes called Pick’s disease) is a relatively rare form of dementia
FTD is thought to account for less than 5% of all dementia cases
It usually affects people between the ages of 45 and 64, but three out of every 10 people with FTD develop the condition at an older age
135
FTD
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
136
Prevalence of FTD
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
The frontal lobes regulate our personality, emotions and behavior, as well as reasoning, planning and decision-making
The temporal lobes are involved in the understanding and production of language
These include
Behavioral variant FTD (bvFTD)
Semantic dementia (SD) (the word semantic means the meaning of language)
Progressive non-fluent aphasia (PNFA) – aphasia is a language disorder where people have problems speaking and writing
FTD associated with motor neuron disease
137
FTD
http://www.alzheimersresearchuk.org/about-dementia/types-of-dementia/frontotemporal-dementia/ftdabout/
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
SD, which has also been called "temporal variant FTD," accounts for 20% of FTD cases
Language difficulty, the predominant complaint of people with SD, is due to the disease damaging the left temporal lobe, an area critical for assigning meaning to words
The language deficit is not in producing speech but is a loss of the meaning, or semantics, of words
138
Semantic Dementia (SD)
http://memory.ucsf.edu/ftd/overview/ftd/forms/multiple/sd
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
PNFA has an insidious onset of language deficits over time as opposed to other stroke-based aphasias, which occur acutely following trauma to the brain
The specific degeneration of the frontal and temporal lobes in PNFA creates hallmark language deficits differentiating this disorder from other Alzheimer type disorders by the initial absence of other cognitive and memory deficits
This disorder commonly has a primary effect on the left hemisphere, causing the symptomatic display of expressive language deficits (production difficulties) and sometimes may disrupt receptive abilities in comprehending grammatically complex language
139
Progressive Non-Affluent Aphasia (PNFA)
M. Hunter Manasco (2014). Introduction to Neurogenic Communication Disorders. pp. 86–88.
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Personality changes
This may include a change in how people express their feelings towards others or a lack of understanding of other people’s feelings
They may also show alack of interest or concern, become disinhibited or behave inappropriately
Lack of personal awareness
People may fail to maintain their normal level of personal hygiene and grooming
Lack of social awareness
This might include making inappropriate jokes or showing a lack of tact
Diet
Changes in food preference, over-eating or over-drinking
140
Symptoms
What is frontotemporal dementia?
http://www.alzheimersresearchuk.org/wp-content/uploads/2015/02/What-is-frontotemporal-dementia-Jan16-WEB.pdf
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Behavior changes
Humor or sexual behavior may change
May become more aggressive, develop unusual beliefs, interests or obsessions
May become impulsive or easily distracted
Decision making
Difficulty with simple plans and decisions
Awareness
Lack of awareness of any changes in their personality or behavior
Language
Decline in language abilities
Might include difficulty getting words out or understanding them
May repeat commonly used words and phrases, or forget the meaning of words
141
Symptoms
What is frontotemporal dementia?
http://www.alzheimersresearchuk.org/wp-content/uploads/2015/02/What-is-frontotemporal-dementia-Jan16-WEB.pdf
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Recognition
Difficulty recognizing people or knowing what objects are for
Memory
Day-to-day memory may be relatively unaffected in the early stages, but problems with attention and concentration could give the impression of memory problems
Movement problems
Around one in every eight people with behavioral variant FTD also develops movement problems of motor neuron disease
This can include stiff or twitching muscles, muscle weakness and difficulty swallowing
142
Symptoms
What is frontotemporal dementia?
http://www.alzheimersresearchuk.org/wp-content/uploads/2015/02/What-is-frontotemporal-dementia-Jan16-WEB.pdf
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
The following abilities in the person with FTD are preserved
Perception
Spatial Skills
Memory
Praxis
143
Preserved Abilities
Snowden JS, Neary D, Mann DM; Neary; Mann (February 2002). "Frontotemporal dementia". Br J Psychiatry. 180 (2): 140–3.
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
© Elisever Inc – Netterimages.com
144
FTD
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Clinical Features Frontotemporal Dementia Alzheimer’s Disease
Age at onset Rarely > 75 years Increases markedly with age
Early behavioral problems Common Unusual
Socially inappropriate behavior
Common early in course Usually in severe case
Memory impairment Less prominent in early course Early and profound impairment
Language problems May have isolated problems without memory impairment
Usually associated with memory impairment
Visuopatial defect Rare in mild to moderately impaired case Less common
Motor signs More common (motor neuron disease) Less common
Mood Marked irritability, anhedonia, withdrawal, difficulties in understanding, processing or describing emotions; euphoria, lack of guilt, apathy or suicidal ideation
Sadness, tears, anhedonia
Psychotic features Rare persecutory delusion, usually jealous, somatic, religious and bizarre behaviors
Usually have delusion of misidentification or persecutory type and usually occur in middle or late stage
Appetite, dietary change Increased appetite, carbohydrate craving 80%, weight gain
Less common: anorexia and weight loss
145
FTD vs Alzheimer’s
W Muangpaisan clincial differences among Four common Dementia syndromes. Geriatrics 7 Aging July/August 2007 volume 10 Number 7
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
DLB is a type of progressive neurodegenerative dementia closely associated with Parkinson's disease primarily affecting older adults
Its primary feature is a more rapid cognitive decline than with Parkinson's, which may lead to hallucinations, as well as varied attention and alertness when compared to a person's baseline function
146
Dementia with Lewy Bodies (DLB)
http://www.lbda.org/node/14
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
http://www.textmed.com/heatmaps/unknown/dementia-with-lewy-bodies-us-heatmap.gif
147
Prevalence of DLB
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
148
© Elisever Inc – Netterimages.com https://alzheimersnewstoday.com/wp-content/uploads/2014/12/
shutterstock_227273575.jpg
Lewy Bodies
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
http://www.sheffieldneurogirls.com/our-brain/substantia-nigra-1
149
Brain Anatomy
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
150
Dopamine is a neurotransmitter that helps control the brain's reward and pleasure centers
Dopamine also helps regulate movement and emotional responses, and it enables us not only to see rewards, but to take action to move toward them
https://www.psychologytoday.com/basics/dopamine https://www.psychologytoday.com/blog/evolutionary-psychiatry/201105/dopamine-primer
What is Dopamine?
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
The hallmark brain abnormalities linked to DLB are named after Frederick H. Lewy, M.D., the neurologist who discovered them while working in Dr. Alois Alzheimer's laboratory during the early 1900s
Most experts estimate that dementia with Lewy bodies is the third most common cause of dementia after Alzheimer's disease and vascular dementia, accounting for 10 to 25 percent of cases
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DLB
http://www.alz.org/dementia/dementia-with-lewy-bodies-symptoms.asp
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Many people with Parkinson's eventually develop problems with thinking and reasoning, and many people with DLB experience movement symptoms, such as hunched posture, rigid muscles, a shuffling walk and trouble initiating movement
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DLB and Parkinson’s
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Changes in thinking and reasoning
Confusion and alertness that varies significantly from one time of day to another or from one day to the next
Parkinson's symptoms, such as a hunched posture, balance problems and rigid muscles
Visual hallucinations
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Symptoms
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Delusions
Trouble interpreting visual information
Acting out dreams, sometimes violently, a problem known as rapid eye movement (REM) sleep disorder
Malfunctions of the "automatic" (autonomic) nervous system
Memory loss that may be significant but less prominent than in Alzheimer's
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Symptoms
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Memory loss tends to be a more prominent symptom in early Alzheimer's than in early DLB, although advanced DLB may cause memory problems in addition to its more typical effects on judgment, planning and visual perception
Movement symptoms are more likely to be an important cause of disability early in DLB than in Alzheimer's, although Alzheimer's can cause problems with walking, balance and getting around as it progresses to moderate and severe stages
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Key Differences Between Alzheimer's and DLB
http://www.alz.org/dementia/dementia-with-lewy-bodies-symptoms.asp
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Hallucinations, delusions, and misidentification of familiar people are significantly more frequent in early-stage DLB than in Alzheimer's
REM sleep disorder is more common in early DLB than in Alzheimer's
Disruption of the autonomic nervous system, causing a blood pressure drop on standing, dizziness, falls and urinary incontinence, is much more common in early DLB than in Alzheimer's
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Key Differences Between Alzheimer's and DLB
http://www.alz.org/dementia/dementia-with-lewy-bodies-symptoms.asp
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Clinical Features Lewy Bodies Alzheimer’s Disease
Isolated Memory impairment 93.8% 31.3%
Parkinsonism More common Less common and usually develops later in the course
Psychiatric symptoms More likely to occur with dementia symptoms early in the course
Less likely
Fluctuation of cognitive function 50-75% When delirious
Verbal memory Better Worse
Type of memory impairment Semantic memory Episodic memory
Executive function Poor early in the course Less severe in early phase
Attention, visuopatial function, constructional abilities
More impairment Less impairment
Visual hallucinations Common since early phase Less prominent in early course
Autonomic involvement Common Less common
Neuroleptics response Extrapyramidal side effect, may cause mortality
Behavioral response
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DLB vs Alzheimer’s
W Muangpaisan clincial differences among Four common Dementia syndromes. Geriatrics 7 Aging July/August 2007 volume 10 Number 7
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Vascular dementia is dementia caused by problems in the supply of blood to the brain, typically a series of minor strokes, leading to worsening cognitive decline that occurs step by step
Consists of a complex interaction of cerebrovascular disease and risk factors that lead to changes in the brain structures due to strokes and lesions, and resulting changes in cognition
The temporal relationship between a stroke and cognitive deficits is needed to make the diagnosis
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Vascular Dementia
Cunningham, EL; McGuinness, B; Herron, B; Passmore, AP (May 2015). "Dementia.". The Ulster medical journal. 84 (2): 79–87
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http://www.textmed.com/heatmaps/disease/vascular-dementia-us-heatmap.gif
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Prevalence of Vascular Dementia
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Confusion
Trouble paying attention and concentrating
Reduced ability to organize thoughts or actions
Decline in ability to analyze a situation, develop an effective plan and communicate that plan to others
Difficulty deciding what to do next
Problems with memory
Restlessness and agitation
Unsteady gait
Sudden or frequent urge to urinate or inability to control passing urine
Depression
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Vascular Dementia Symptoms
http://www.mayoclinic.org/diseases-conditions/vascular-dementia/basics/symptoms/con-20029330
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https://www.healthtap.com/user_questions/111973
Vascular Dementia
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Hachinski VC, Iliff LD, Zilhka E, Du Boulay GH, McAllister VL, Marshall J, Russell RW, Symon L. “Cerebral blood flow in dementia.”
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Hachinski Ischemia Score
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Clinical Features Vascular Dementia Alzheimer’s Disease
History of atherosclerotic disease
TIAs, strokes, atherosclerotic risk factors (diabetes, hypertension)
Less Common
Onset Sudden or gradual Gradual
Progression Slow or stepwise progression Slow, progressive decline
Neurological examination
Neurological deficits Normal
Gait Often disturbed early Usually normal
Memory Mild Impairment in Early phase Prominent in early phase
Executive Function Marked impairment and early Impaired later
Type of dementia Subcortical Cortical
Hashinski Ischemic Score
> 7 < 4
Neuroimaging Infarction or white matter lesions Normal or Hippocampal atrophy
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Vascular Dementia vs Alzheimer’s
W Muangpaisan clincial differences among Four common Dementia syndromes. Geriatrics 7 Aging July/August 2007 volume 10 Number 7
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Memory impairment
Disorientation to place
Impairment of judgement
Language impairment
Decline in capabilities and routine activities of daily living
Change in personality and/or marked difficulty maintaining social function
Changes in expressions of feelings
Thinking disturbances
Questions to ask for memory loss
Orientation to place
Judgement
Language
Capabilities and activities of daily living
Sociability
Expression of feelings
Thinking
Dementia Documentation
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Promotes comfort and quality of life without use of life extending measures
Focuses on close, collaborative working relationships between health care team, family, and patient
Provides education that will allow the family to make informed decisions about the patient’s healthcare needs
Involvement of spiritual and religious counsel
Assistance with the grieving process
Knowledge that dementia is a terminal illness
Offers diverse comfort measures to promote end of life care and quality of life
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Hospice Goals for Dementia Patients
Smith, M. (2007). Hospice Approach to End of Life Dementia Care. University of Iowa College of Nursing Iowa Geriatric Education Center
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Terminal phase of dementia may be prolonged and difficult to predict
People with end stage dementia lack the decision making skills to elect hospice services independently
Patient’s did not make their wishes known prior to becoming incompetent
The patient may not appear as if they are terminal
Lack of education that dementia is a terminal illness
Medicare hospice eligibility requirements
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Barriers to Providing Hospice Services
Smith, M. (2007). Hospice Approach to End of Life Dementia Care. University of Iowa College of Nursing Iowa Geriatric Education Center
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Brief Cognitive Rating Scale (BCRS)
Pt Name: Medication: Age: Sex:
M F Diagnosis: Date: s
Axle Rating (Circle Highest Score) 1 2 3 4 5 6 7
Axis 1: Concentration
1 - No objective or subjective evidence of deficit in concentration
2 - Subjective decrement in concentration ability
3 - Minor objective signs of poor concentration (e.g. on subtraction of serial 7s from 100)
4 - Definite concentration deficit for persons of their background (e.g. marked deficit on serial 7s; frequent deficit in subtraction of serial 4s from 40)
5 - Marked concentration deficit (e.g,, giving months backwards or serial 2s from 20)
6 - Forgets the concentration task. Frequently begins to count forward when asked to count backwards from 10 by 1s
7 - Marked difficulty counting forward to 10 by 1s
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Brief Cognitive Rating Scale (BCRS) Axis 1: Concentration
Reisberg, B. & Ferris S.H. (1988). Brief Cognitive Rating Scale. Psychopharmacology Bulletin, 24(4), 629-636.
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1 - No objective or subjective evidence of deficit in recent memory
2 - Subjective impairment only (e.g., forgetting names more than formally)
3 - Deficit in recall of specific events evident upon detailed questioning. No deficit in the recall of major recent event.
4 - Cannot recall major events of previous weekend or week. Scanty knowledge (not detailed) of current events, favorite TV shows etc.
6 - Unsure of weather: may not know current President or current address
7 - Occasional knowledge of some recent events. Little or no idea of current address.
8 - No knowledge of any recent events
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Axis 2: Recent Memory
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1 - No subjective or objective impairment in past memory
2 - Subjective impairment only. Can recall two or more primary school teachers.
3 - Some gaps in past memory upon detailed questioning. Able to recall at least one childhood teacher and/or one childhood friend.
4 - Clear cut deficit. The spouse recalls more of the patients past than the patient. Cannot recall childhood friends and/or teachers but knows the names of most schools attended. Confuses chronology in reciting personal history.
5 - Major past events sometimes not recalled (e.g, names of schools attended)
6 - Some residual memory of past (e.g.. may recall country of birth or former occupation)
7 - No memory of past
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Axis 3: Past Memory
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1 - No deficit in memory for time, place. Identity of self and others.
2 - Subjective impairment only. Knows time to nearest hour, location.
3 - Any mistake in time> 2 hrs: day of week> 1 day; date> 3 days
4 - Mistakes in month> 10 days or year> 1 month
5 - Unsure of month and/or year and/or season: unsure of locale
6 - No idea of date. Identifies spouse but may not recall name. Knows own name.
7 - Cannot identify spouse. May be unsure of personal identity.
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Axis IV: Orientation
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1 – No difficulty, either subjectively or objectively
2 - Complains of long forgetting location of objects, subjective work difficulties
3 - Decreased job functioning evident to co-workers. Difficulty in traveling to new locations.
4 - Decreased ability to perform complex tasks (e.g. planning dinner for guests, handling finances, marketing, etc.). 5 - Requires assistance in choosing proper clothing.
6 - Requires assistance in feeding, and/or toileting, and/or bathing, and/or ambulating
7 - Requires constant assistance in all activities of daily living
Total Score divide by 5.0 = Stage on
Global Deterioration Scale
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Axis V: Functioning and Self-Care
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Ratings: Taking into account the subject's level or education cultural background, etc. the interviewer rates each clinical axis on the BCRS on a scale ranging from 1 to 7. These scale points define the degree of impairment on each axis as follows.
1 – Normal: No cognitive decline present. Average or better performance
2 - Very mild: Subjective impairment in comparison with 5 or 10 years previous
3 – Mild: Minimal impairment which is clinically verifiable with detailed questioning
4 – Moderate: Marked impairment which is readily evidenced clinically
5 - Moderately Severe: Severe impairment on assessment
6 – Severe: Very severe impairment; some residual capacity in some assessment areas
7 - Very severe: Very severe impairment; little residual capacity elicited in assessments
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Guidelines for Scoring BCRS
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Reisberg, B., Ferris, S.H., de Leon, M.J., and Crook, T. The global deterioration scale for assessment of primary degenerative dementia. American Journal of Psychiatry, 1982, 139: 1136-1139.
Copyright © 1983 by Barry Reisberg, M.D. Reproduced with permission.
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Reisberg, B., Ferris, S.H., de Leon, M.J., and Crook, T. The global deterioration scale for assessment of primary degenerative dementia. American Journal of Psychiatry, 1982, 139: 1136-1139.
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1. Not calm
2. Screams
3. Pain
4. Decubitus ulcers
5. Malnutrition
6. Eating disorders
7. Invasive action
8. Unstable medical condition
9. Suffering according to medical opinion
10. Suffering according to family opinion
Aminoff BZ, Gerontologie und Geriatrie 1999; Aminoff BZ, Purits E, Noy S, Adunsky A. Measuring the suffering of end-stage dementia: reliability and validity of the Mini-Suffering State Examination.
Arch Gerontol Geriatr 2004;38(2):123-130.
Suffering items Yes (1)/no (0)
Mini Suffering State Exam
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Blessed G, Tomlinson BE, Roth M. “The association between quantitative measures of dementia and of senile change in the cerebral grey matter of elderly subjects. Br J Psychiatry. 1968;114:797-811.
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Borson S, Scanlan JM, Chen PJ et al. The Mini-Cog as a screen for dementia: Validation in a population-based sample. J Am Geriatr Soc 2003;51:1451–1454.
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC) 178
Nasreddine, Ziad S.; Phillips, Natalie A.; Bédirian, Valérie; Charbonneau, Simon; Whitehead, Victor; Collin, Isabelle; Cummings, Jeffrey L.; Chertkow, Howard (2005-04-01). "The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment". Journal of the American Geriatrics Society. 53 (4): 695–699.
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Copyright 1993-2005 Albert Einstein College of Medicine.
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC) 180
Int J Geriatr Psychiatry. 2006 Nov;21(11):1078-85.
The Addenbrooke's Cognitive Examination Revised (ACE-R): a brief cognitive test battery for dementia screening.
Mioshi E1, Dawson K, Mitchell J, Arnold R, Hodges JR.
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© University of New South Wales as represented by the Dementia Collaborative Research Centre – Assessment and Better Care;
Brodaty et al, JAGS 2002; 50:530-534
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by A. F. Jorm Short Form of the Informant Questionnaire on Cognitive
Decline in the Elderly (Short IQCODE)
Short Form of the Informant Questionnaire on Cognitive Decline in the Elderly (Short IQCODE)
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Adapted from Galvin JE et al, The AD8, a brief informant interview to detect dementia, Neurology 2005:65:559-564
Copyright 2005. The AD8 is a copyrighted instrument of the Alzheimer’s Disease Research Center, Washington University, St. Louis, Missouri.
All Rights Reserved
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Part 2
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What You Need to Know for 2017
Data Driven Topics
Hospice Election Statement
Medicare Secondary Hospice Election
Transfer Requirements
Billing Dispute Resolution Requests
Comparative Billing Report (CBR)
CERT Program
Provider Enrollment Revalidation
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Agenda
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eServices Online Provider Portal
Provider Resources/Self Service Tools
Secure eChat
Tools and Calculators
Social Media
E-Mail Updates
Hospice Basics Modules
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Agenda
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F isca l Year (FY ) 2017 Hospice F ina l Ru le
Hospice Center
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What You Need to Know for 2017
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FY 2017 Final Rule – Key Points
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
The 2017 Hospice Final Rule includes
Hospice wage index for all four levels of care and hospice cap amount
Implemented October 1, 2016, with CR 9729
Hospice Quality Reporting Program (HQRP), including two new quality measures and enhancements for the Hospice Item Set (HIS)
Awaiting further direction from CMS
Information regarding the Medicare Care Choices Model (MCCM)
Informational only
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H o s p i c e E l e c t i o n S t a t e m e n t – O I G R e p o r t O E I - 0 2 - 1 0 - 0 0 4 9 2
M e d i c a r e S e c o n d a r y H o s p i c e E l e c t i o n – I n q u i r y A n a l y s i s
T r a n s f e r R e q u i r e m e n t s – I n q u i r y A n a l y s i s
C o m p a r a t i v e B i l l i n g R e p o r t ( C B R )
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Data Driven Topics 189
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Hospice election statements
Did not specify Medicare
Required waiver information was missing or was stated inaccurately
Required information about palliative care was missing
Revocation or discharge information was inaccurate or unclear
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Hospice Election Statement - OIG Findings
https://oig.hhs.gov/oei/reports/oei-02-10-00492.pdf
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Election statements did not specify that the beneficiary was electing was Medicare hospice
Patient/Representative must elect to receive the benefit
Patient/Representative must sign an election statement acknowledging that he/she wishes to enroll in the MHB
Patient/Representative must acknowledge understanding of coverage for hospice care under the Medicare program
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Inside the OIG Findings
https://oig.hhs.gov/oei/reports/oei-02-10-00492.pdf
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Required waiver information was missing or was stated inaccurately (e.g., beneficiary waives the right to “all” other benefits under the Medicare program while receiving hospice benefits)
Patient must understand that once the MHB is elected, payment of Medicare benefits for services related to the terminal illness is only made to the hospice
Coverage of services not related to the terminal illness are paid under the traditional fee-for-service program
Hospice is responsible for maintaining and facilitating any care the patient needs
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Inside the OIG Findings
https://oig.hhs.gov/oei/reports/oei-02-10-00492.pdf
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Required information about palliative care was missing
The patient must acknowledge understanding that hospice care is palliative and not curative
Palliative care means the patient and family-centered care that optimizes the quality of life by anticipating, preventing, and treating suffering
Patients that choose to receive curative treatments do not qualify for the MHB
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Inside the OIG Findings
https://oig.hhs.gov/oei/reports/oei-02-10-00492.pdf
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Revocation or discharge information was inaccurate or unclear
Some election statements indicated that if patient chose care or treatment that was not preauthorized by the hospice or was not included in the plan of care, patient would immediately be removed from the MHB
The patient must choose to revoke the MHB, and must do so in writing
Hospices must notify the patient in advance if they are discharging
Information on revocation and discharge not required on election statement
If revocation and/or discharge information is included on the election statement, it must be clear to the patient that Medicare payment for hospice care ends
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Inside the OIG Findings
https://oig.hhs.gov/oei/reports/oei-02-10-00492.pdf
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Each hospice designs and prints its election statement
As you develop your own Hospice election statements and certifications of terminal illness, please review the MLN Matters Special Edition Article SE1631 (https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se1631.pdf) for
Specific requirements you must include for valid documentation
Example text
Information can be all on one document or multiple documents
If more than one document, ensure that all documents are submitted with the medical record
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Election Statement Requirements
CMS IOM Publication 100-02, Chapter 9, Section 20.2.1
MLN Matters ® Article – SE1631
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
The examples on the following slides and in the MLN Matters® article SE1631 are for illustrative purposes only, and they do not imply this is the only acceptable format
Hospice providers may use these examples as they design their own forms or format to ensure their election statements are valid and meet all requirements
Disclaimer: Election Statement Example
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Must include information of the particular hospice that will provide care and the beneficiary’s name
I, choose to elect the Medicare hospice
(Beneficiary Name) benefit and receive Hospice services from .
(Hospice Agency)
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Election Statement: Requirement 1
MLN Matters ® Article – SE1631
Example:
Note: The beneficiary/representative is not required to hand write this information on the form. The hospice can preprint the name of their agency on the form.
Full understanding of hospice care
Information must be clear to the patient that the care to be provided is palliative and not curative
Language should be in simple terms that the beneficiary/representative can understand
Includes alternate languages (e.g., Spanish)
Does not have to be on the same page, but must be clear that the beneficiary/representative understands what hospice care is
I acknowledge that I have been given a full explanation and have an understanding of the purpose of hospice care. Hospice care is to relieve pain and other symptoms related to my terminal illness and related conditions and such care will not be directed toward cure. The focus of hospice care is to provide comfort and support to both me and my family/caregivers.
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Election Statement: Requirement 2
MLN Matters ® Article – SE1631
Example:
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Effects of a Medicare election
Beneficiary/representative must waive rights to Medicare payments under the traditional fee-for-service program for services related to the terminal illness
Payment for related services will only be made to the hospice and attending physician (if there is one)
I understand that by electing hospice care under the Medicare Hospice Benefit, I am waiving (giving up) all rights to Medicare payments for services related to my terminal illness and related conditions and I understand that while this election is in force, Medicare will make payments for care related to my terminal illness and related conditions only to the designated hospice and attending physician that I have selected. I understand that services not related to my terminal illness or related conditions will continue to be eligible for coverage by Medicare.
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Election Statement: Requirement 3
MLN Matters ® Article – SE1631
Example:
Designated attending physician (if any)
Beneficiary has the right to choose an attending physician
Is not required to choose an attending physician
Election statement must clearly state that patient was given a choice
I understand that I have a right to choose my attending physician to oversee my care. My attending physician will work in collaboration with the hospice agency to provide care related to my terminal illness and related conditions.
☐ I do not wish to choose an attending physician
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Election Statement: Requirement 4
MLN Matters ® Article – SE1631
Example:
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Designated attending physician (if any);
If attending physician is selected, the election statement must include the full name of the physician or nurse practitioner selected
The election may also include other information such as
NPI of Physician or NP
Address of Physician or NP
I acknowledge that my choice for an attending physician is:
Physician Full name: NPI (if known)
Office Address:
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Election Statement: Requirement 4
MLN Matters ® Article – SE1631
Example:
The effective date of the election
May be the first day of hospice care or a later date
May be no earlier than the date of the election statement is signed
Beneficiary may not designate an effective date that is retroactive
I acknowledge and understand the above, and authorize Medicare
hospice coverage to be provided by (Hospice Agency)
to begin on (Effective Date of Election)
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Election Statement: Requirement 5
MLN Matters ® Article – SE1631
Example:
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Beneficiary’s or representative’s signature and date
If representative is signing, may include relationship to beneficiary
If beneficiary unable to sign, may include reason why
Witness signature and date may be included
Signature of Beneficiary/Representative (Date)
☐ Beneficiary is unable to sign
Reason: Witness signature (Date)
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Election Statement: Requirement 6
MLN Matters ® Article – SE1631
Example:
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Beneficiaries that have other health insurance that is primary to Medicare may elect the MHB
If the beneficiary elects the MHB, the hospice must submit the NOE and subsequent claims
Regardless of whether or not the primary pays 100% of the charges
The existence of a primary payer source does not negate the Medicare requirements for the MHB
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Medicare Secondary Payer (MSP) and the Hospice Election
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The agency submits the NOE as normal
All claims subsequent to the NOE are submitted to the primary payer first
Upon receipt of the primary payer’s EOB/RA, the hospice submits the claim to Medicare
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MSP and the Hospice Election
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
The claims processing system will calculate as applicable any payment that is due to the provider
Payments are calculated based on the data submitted on the claim
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MSP and the Hospice Election
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A patient may change, once in each election period, the designation of the particular hospice from which he or she elects to receive hospice care
The change of the designated hospice is not considered a revocation of the election, but is a transfer
Where one hospice discharges a patient and another hospice admits the same patient on the same day, each hospice is permitted to bill, and each will be reimbursed at the appropriate level of care (LOC) for its respective day of discharge or admission
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Transfers: Definition
CMS IOM, Publication 100-02, Chapter 9, Section 20.2.1
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
When a new hospice admission occurs after a hospice revocation or discharge that resulted in termination of the hospice benefit, an election date cannot be the same as the revocation or discharge date
A change of ownership (8XE) of a hospice is not considered a change in the patient’s designation of a hospice and requires no action on the patient’s part
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Transfer Requirements
CMS IOM, Publication 100-02, Chapter 9, Section 20.2.1
Change Request 9114
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To change, the patient/representative must file a transfer statement with both hospices
Palmetto GBA’s expectation is that the receiving and/or the transferring hospice will assist the patient/representative with completing the transfer agreement
Both hospices must agree on date of transfer
Valid transfer occurs on the same day or the day after
No gaps in dates of service
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Transfer Requirements
CMS IOM, Publication 100-02, Chapter 9, Section 20.2.1
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
The hospice agency receiving the patient must perform a complete admission
Physician Certification
Election Statement
Plan of Care
A new F2F is not required for transfers that occur in the third or later benefit period if the receiving hospice can verify that the originating hospice had the encounter
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Receiving Agency Requirements
CMS IOM, Publication 100-02, Chapter 9, Section 20.2.1
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Submit the final claim (TOB 8X4)
Ensure the following are included
Through date is the last day the patient was on service with the agency
Patient Discharge Status code must be 50 or 51
50 – Discharged/transferred to hospice (home)
Patient will receive RHC
51 – Discharged/transferred to hospice (medical facility)
Patient will receive GIP or inpatient respite LOC
All other data as normal
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Transferring Hospice: Final Claim
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
The Notice of Change (8XC) notifies the contractor and CWF that the admission is a continuation of the current hospice election period
Receiving hospice must submit an 81C/82C to indicate the patient is transferring agencies
Ensure previous (transferring) hospice has submitted their final claim (8X4)
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Receiving Agency: Notice of Change
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Submit 8XC prior to submitting the first claim
Ensure that the following are included
From date is the date of the transfer
Admit date is the date of the transfer (must match the From date)
Occurrence Code 27 and date
This is the certification date
The date must match the certification date of the transferring hospice
If the transfer date is the same as the certification date, the 8XC is not required
Do not enter a Patient Discharge Status code
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Receiving Agency: Notice of Change
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If hospice agencies follow the transfer requirements, there should not be an overlap in the dates of service
Palmetto GBA’s expectations are that the two agencies attempt to resolve the matter between them
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Handling a Dispute in Transfer Situations
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If the hospice agencies are unable to resolve the matter, Palmetto GBA can intervene
Either the receiving or the transferring hospice agency may request assistance by submitting a Billing Dispute Resolution Request Form
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Handling a Dispute in Transfer Situations
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
When a resolution cannot be reached, submit the Billing Dispute Resolution Request Form
Access the form at www.PalmettoGBA.com/HHH; select “Medicare Forms” in the Forms/Tools box on the home page; select Billing Dispute Resolution Request under the Provider Contact Center heading
Note: The form is not required, but all requests must include the elements contained in the form
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Submitting A Billing Dispute Resolution Request
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The request must include
Copy of the HIQA page 1 (recommended)
Copy of the transfer agreement
Copy of the communication(s) between the hospices (telephone call log, emails, etc.)
Palmetto GBA’s expectation is that the receiving agency has communicated with the initial hospice to facilitate an agreement on the transfer date
Unanswered communications regarding the patient’s desired transfer date are not acceptable
Billing Dispute Request: Receiving Agency
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The request must include
Copy of the transfer agreement (if available)
Copy of the communication(s) between the hospices (telephone call log, emails, etc.)
Transfer situation does not end the patient’s enrollment in the MHB
The patient should not be signing a revocation notice
Billing Dispute Request: Transferring Agency
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Do not wait until the last minute to request assistance from Palmetto GBA
Allow the other hospice agency a reasonable amount of time to complete their billing or make the necessary corrections
Providers that fail to comply with the request from Palmetto GBA will not be granted an exception to the late filing of an NOE or an extension to timely filing requirements on claims if the timely filing should lapse before the matter is resolved
Billing Dispute – Timely Filing Billing Requirements
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Palmetto GBA makes every attempt to resolve billing disputes as quickly as possible
Billing dispute requests are considered to be written correspondence, and Palmetto GBA has up to 45 business days to process written correspondence
Research is done to ensure that the request contains all the required information and supporting documentation (when applicable)
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Palmetto GBA’s Process
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The request will not be processed if
The information and supporting documentation is not received
The provider must submit a new request with the required information and supporting documentation
Claim(s) that is/are past the timely filing requirements
This includes a resubmitted request if the original request was not processed
The provider will be notified in writing of the decision for either situation
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Palmetto GBA’s Process
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
After the research is completed
When appropriate, a letter is mailed to the provider/organization needing to
Complete or back out billing
Adjust the end (transferring hospice) or start (receiving hospice) date
Provide a copy of the transfer agreement
If a response to the letter is not received within 10 business days of the date of the letter, Palmetto GBA will
Cancel claims, NOE/Notice of Change
Adjust the end date on the final claim (transferring hospice)
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Palmetto GBA’s Process
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Comparative Billing Report (CBR)
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CBRs show providers how they compare to their peers in billing for certain risk areas
This report does not contain patient specific data
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CBR
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If you receive a CBR
It is not intended to be punitive, or sent as an indication of fraud
It is a tool for providers to proactively self-audit in order to identify potential errors in their billing and documentation practices
If an error is identified which results in a Medicare overpayment, providers should notify the MAC and submit a voluntary refund
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CBR
What is the CERT Program?
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CERT Program 226
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Federally mandated program created by the Centers for Medicare & Medicaid Services (CMS) to measure the paid claims error rate for Medicare claims submitted to MACs
CMS receives in excess of 2 billion claims per year
Ensures that the Medicare program is paying claims correctly
The CERT program measures national, contractor-specific, and service-specific paid claim error rates
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CERT
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The CERT program uses a random and a service-specific sampling of claims
AdvanceMed is the CERT contractor responsible for administering the CERT program on behalf of CMS
The CERT contractor selects samples of claims from Palmetto GBA
For each claim selected, the CERT contractor requests medical records, from the providers, physicians or suppliers that billed for the services, and prepares the documentation for review
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CERT
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CERT ADR letters are mailed to the provider at the address in their provider enrollment record
Letter will contain a “CID” number that should be included with the response
Providers should ensure their provider enrollment records are up-to-date
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CERT ADR Letters
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Providers may update the contact information that CERT uses
Contact Name
Address
Phone
Fax
Go to www.certprovider.admedcorp.com and select Address Update at the top of the page
Providers may enter a valid National Provider Identifier or a valid contractor ID and valid Provider ID
Valid Contractor ID: 11001
Valid Provider ID: Enter the six-digit Medicare provider number
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CERT Contact Information
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Electronic Submission of Medical Documentation (esMD)
For more information about esMD, see https://www.cms.gov/esMD
Fax
804-261-8100
CD
If mailing a CD, it MUST contain only images in TIFF or PDF format. Please be sure that all information is encrypted and protected by a password
Send the password via email to [emailprotected].
Paper Attn: CID XXXXXXX CERT Documentation Center 1510 East Parham Road Henrico, VA 23228
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CERT Documentation Submission
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Identify Improper Payments
Submit Claim Adjustment to MAC When Error Identified
If No Error Identified – No Action is Taken
Respond to any audit specific questions you may have, such as
their rationale for identifying the potential improper payment
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CERT Contractor Responsibilities
mailto:[emailprotected]
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Perform claim adjustments
based on the CERT’s review if
improper payment was
identified
•CERT adjusted claims are
identified by type of bill
(TOB) xxH
Issue demand letters for
overpayments generated for
improper payments
•Demand letters will be sent
to the provider’s physical
address
Handle administrative
concerns such as timeframes
for payment recovery and the
redeterminations
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MAC Contractor Responsibilities
Joint effort of the
Part A/B
Medicare
Administrative
Contractors
(MACs)
Designated Task
Force members
from each MAC
work together to
educate and
communicate
national issues of
concern regarding
improper payments
to the Medicare
program
Task Force
education
intended to
complement CMS
and MAC
individual error-
reduction
activities
Share common
goal of reducing
the national
improper
payment rate as
measured by the
Comprehensive
Error Rate
Testing (CERT)
program
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Medicare A/B MAC CERT Task Force
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Medicare A/B MAC CERT Task Force
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CMS Program Integrity Manual
www.cms.gov/manuals/downloads/pim83c12.pdf
Publication 100-08
CERT Provider website
https://www.certprovider.admedcorp.com
CMS CERT website
www.cms.gov/CERT
CERT resources on JM HHH website
www.PalmettoGBA.com/HHH
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CERT Resources
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MLN Matters® Number: SE1605
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Provider Enrollment Revalidation
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Requires all providers/suppliers to resubmit and recertify the accuracy of enrollment information
All providers/suppliers must be revalidated under the new enrollment screening criteria
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Provider Enrollment Revalidation
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CMS has established dates by which providers/suppliers must revalidate
To make it easier, when a provider is asked to revalidate, the due date assigned will always be on the last day of the month specified (e.g. June 30, July 31, August 30)
With subsequent revalidation cycles, provider’s due dates will generally remain the same
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Provider Enrollment Revalidation – Due Dates
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
To assist providers, the CMS developed a Lookup Tool
It will display
All currently enrolled providers/suppliers
A due date or an indication of a ‘TBD’ in the due date field
To Be Determined (more than 6 months until your due date)
Due dates will be posted up to 6 months before revalidation due date and are updated periodically
https://data.cms.gov/revalidation
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Provider Enrollment Revalidation – Due Dates
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When you receive your Cycle 2 Revalidation letter
Pay close attention to the due date and plan according to revalidate by the due date
Revalidate your Medicare enrollment record through www.PECOS.cms.hhs.gov, or appropriate form CMS-855
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The Revalidation Process
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Palmetto GBA will issue revalidations letters within 2-3 months of a given provider’s established due date
Notices will be sent 1 of 2 methods
eServices for providers currently enrolled in Palmetto GBA’s self-service portal
Standard mail
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Revalidation Letters
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Each provider/supplier is required to revalidate their entire Medicare enrollment record
Failure to take necessary actions to complete revalidation when requested, could result in a hold on Medicare payments and possible deactivation of your Medicare billing privileges
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Reminders
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Providers/Suppliers deactivated will be required to submit a new full and complete application in order to reestablish their provider enrollment record and related Medicare billing privileges
Use the CMS Lookup Tool to view the due date
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Reminders
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eServices Online Provider Portal
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January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Palmetto GBA’s goal is to give the provider secure and fast access to Medicare information seamlessly via our website through the eServices application
Palmetto GBA’s eServices is a free Internet-based, provider self-service secure application
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eServices Goal
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Eligibility
Claims Status
Remittances Online
Financial Information – payment floor and last three checks paid
Financial Forms – eOffset requests, eCheck payments and CMS-838 Credit Balance form (Part A and HHH only)
Secure Forms – Appeals, Cost Report Form (Part A and HHH only), Medical Review ADR Response Form, and General Inquiry form
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eServices Functions
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
eReview – Electronic Review
eCBR New! – Electronic Comparative Billing Report (eCBR)
Non-Cancer Length of Stay (NCLOS) rates from April 1, 2016 to September 30, 2016
eAudit New! – Electronic Audit
CERT audit data by error code category
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eServices Functions
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No cost for registering and using eServices
You can participate in eServices if you have a signed EDI Enrollment Agreement on file with Palmetto GBA
The person who registers is the provider administrator that
Grants access for additional users to access
Views and prints information from eServices related to registered provider
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eServices Key Points
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
The provider administrator’s responsibilities include the following
Creating and maintaining user profiles
Assigning application permissions to the provider user
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eServices Administrator
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Create additional provider administrators
Ensure you have at least 1 back-up administrator
If the initial administrator leaves your agency without assigning another administrator, contact the EDI department to change administrators on file
Terminating users or administrators
A user will continue to have access until they are terminated or fail to login once every 60 days
New provider administrator can login and delete the old provider administrator
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eServices Administrator
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
eCBR information is located under the eReview tab
One of the many tools used to assist individual providers to become proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare guidelines
Personalized NCLOS eCBR results
April 1, 2016 to September 30, 2016
Only available in eServices
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NEW!!! - eCBR
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eAudit is located under the eReview tab
Allows providers the ability to access personal reports of audit results for claims which have been chosen for Complex Medical Review by various Medicare review contractors
Gives providers the opportunity to see what claims may be pending Complex Medical Review currently and the results of any recent review decisions
Information can be used for self-assessment of provider performance on Medicare audits utilizing a dashboard which contains the most common denial reasons
Currently features CERT audit data by error code category
NEW!!! - eAudit
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eAudit
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Users no longer need a separate login for each PTAN and NPI combination
Users have the ability to link their previously assigned eServices user ID’s under one default ID
Any additional PTAN/NPI combinations for which an account is not set up, a provider administrator must create the account before it can be linked
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NEW!!! - Account Linking
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Getting started is simple
Log into eServices with the user ID that you wish to designate as your default login ID
This is the user ID that will be used to access the linked accounts
Once you have successfully logged into eServices, select the My Account tab and then access the Account Linking sub-tab
Choose the accounts you wish to link
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Account Linking
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Once user accounts are linked the user will
Be able to login one time
Click a drop down menu that lists all linked NPI and PTAN combinations attached to the user ID
Select the individual account he/she would like to view
Providers are only able to link active eServices accounts
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Account Linking
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Account Linking
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
User cannot link accounts that are already linked to a default user ID
User cannot link accounts that are inactive or have been terminated for any reason such as
Terminated by the provider administrator
Terminated by Palmetto GBA
Terminated for inactivity (no login for 60 days)
Terminated for not completing recertification or verification timely
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Account Linking
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Account Linking
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Multi-factor authentication is an extra layer of security
Logging into your eServices account will work a little differently
1. You'll enter your password as usual
2. Then, you’ll select your preferred method of delivery between email or a text message
3. Once you receive your verification code you will enter it in the verification box and you're in
Mandatory April 1, 2017
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Multi-Factor Authentication
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eServices References
Secure eChat
Tools and Ca lcu lators
Soc ia l Media
Emai l Updates (L is tserv )
Hospice Bas ics Tra in ing Modules
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Provider Resources/Self Service Tools
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During certain business hours, secure eChat is available on Palmetto GBA’s website
Look for the icon at the bottom right side of the screen
The icon will be displayed when our eChat feature is available
This feature gives providers
A method to ask questions about Medicare regulations and guidelines
Request assistance with finding information on Palmetto GBA’s or CMS’ websites
Discuss claim specific information to include PHI because it is a secure connection
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Secure eChat
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Tools and Calculators
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Forms
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Note: Please complete the form online
Forms
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Social Media: Facebook
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Social Media: Twitter
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YouTube
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Stay Up-to-Date with Email Updates
• Not registered? – Click Register Now, complete the fields and hit “Register” button at the bottom of the page
• Be sure to follow the instructions when you receive the confirmation email to finalize your registration
January 2017 Palmetto GBA - Medicare Administrative Contractor (MAC)
Use the Hospice Basics Training Modules for your basic training needs
From the HHH Homepage
Click on the arrow next to
Select from the options in the drop down
Select
Click on
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Hospice Basics Training Modules
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Questions???