Diagnoses on Hospice Claims – Further Clarification
May 28, 2013 03:09 PM
Since the fiscal year (FY) 2014 Hospice Wage Index proposal was posted just several weeks ago, hospices have been asking numerous questions about the Centers for Medicare & Medicaid Services’ (CMS) clarification of diagnoses on hospice claims - and hospices have been debating answers to the numerous questions and what steps hospices should take to be in full compliance with CMS’ expectations.
One of the most frequently asked questions is “When will Medicare’s Administrative Contractors (MACs) begin returning to provider (RTP) hospice claims that have ‘adult failure to thrive’ or ‘debility’ as the principal diagnosis?”
In a recent Open Door Forum (ODF), CMS indicated this would be “soon” and instructions to MACs were “in process." Since the ODF, the National Association for Home Care & Hospice (NAHC) has clarified with CMS that it will use the same process used for all instructions to MACs. This means the instructions will be delivered via a Change Request (CR). The CR will include an effective date and an implementation date - as all CRs do - but NAHC does not yet know exactly how much time there will be between the release of the CR and its implementation date and effective date.
In the proposed rule, CMS indicated that it is seeking comments about these diagnoses but we are not certain that CMS will wait until after those comments are received and reviewed before releasing the CR. It is, however, NAHC's understanding from CMS that all claims RTP’d will be for a date in the future. There will be no retrospective returns to provider. Again, at this time the only change that CMS has indicated will occur in the near future is that hospice claims with ‘adult failure to thrive’ or ‘debility’ as the principal diagnosis will be RTP’d. The purpose of returning the claim to the provider is so CMS can request the hospice to use a different, more specific and causative, diagnosis as the principal diagnosis. If the hospice cannot provide a different, more specific diagnosis we expect the claim will be denied.
CMS has clearly stated that hospices need to use the ICD-9 coding guidelines when determining the principal diagnosis and all other diagnoses. This has been very confusing to hospices, in part, because some MACs use diagnosis-specific LCDs as criteria for hospice eligibility and some have LCDs for ‘adult failure to thrive’ and ‘debility’. CMS stressed to NAHC that hospice eligibility is determined by a patient’s prognosis not a patient’s diagnosis.
NAHC and HAA fully understand the confusion hospices are experiencing as well as the need for hospices to follow ICD-9 coding guidelines. Hence, both organizations will continue to work on developing educational resources to assist hospices.
In the interim, It is suggested that hospices thoroughly review each case where ‘debility’ or ‘adult failure to thrive’ is listed as the principal diagnosis, and code the diagnosis that is most contributory to the debility or the adult failure to thrive as the principal diagnosis for all future claims.
There has been some concern from hospices that the most contributory diagnosis is not always a “hospice diagnosis” - and that the hospice and the hospice physician is not comfortable putting the “non-hospice diagnosis” on the claim as the principal diagnosis.
It is the prognosis of the patient that determines eligibility and not the diagnosis and the hospice needs to follow the ICD-9 coding guidelines and code the most contributory diagnosis as the principal diagnosis.
There remain questions about how the MACs may modify their LCDs and corresponding education to providers upon the release of the anticipated CR on this subject. CMS made it clear in the ODF that national guidance supersedes any local coverage determinations. We also understand that there remain questions about the impact on the certification of terminal illness (CTI) in cases where a diagnosis of ‘adult failure to thrive’ or ‘debility’ needs to be changed in accordance with ICD-9 coding guidelines. NAHC and HAA continue to seek guidance in this area as well as other areas where clarity is needed.
NAHX and HAA also continue to seek guidance and provide education regarding the listing of multiple diagnoses on hospice claims – the principal diagnosis and all related diagnoses.
NAHC and HAA need information from hospices.
Specifically, please share with us the following:
1. If utilizing an EMR, is the system able to differentiate between related and unrelated diagnoses and only put related diagnoses on the claim?
2. Specific clinical conditions of cases in which a patient is clearly terminal but a diagnosis more specific than adult failure to thrive or debility does not appear to be present.
Please provide us with this information as soon as possible. You can submit it to Theresa Forster, firstname.lastname@example.org, or Katie Wehri, Katie@nahc.org.