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In the various roles he has undertaken through the years, Val J. Halamandaris has been a singular driving force behind the policy and program initiatives resulting in the recognition of home health care as a viable alternative to institutionalization. His dedication to consumer advocacy, which enhances the quality of life and dignity of those receiving home health care, merits VNA HealthCare Group’s highest recognition and deepest respect. 

VNA HealthCare Group

I have the highest respect for them, especially for the nurses, aides and therapists, who devote their lives to caring for people with disabilities, the infirm and dying Americans.  There are few more noble professions.

President Barack Obama

Home health care agencies do such a wonderful job in this country helping people to be able to remain at home and allowing them to receive services

U.S. Senator Debbie Stabenow (D-MI) Chair, Democratic Steering and Outreach Committee

Home care is a combination of compassion and efficiency.  It is less expensive than institutional care...but at the same time it is a more caring, human, intimate experience, and therefore it has a greater human’s a big mistake not to try to maximize it and find ways to give people the home care option over either nursing homes, hospitals or other institutions

Former Speaker of the U.S. House of Representatives Newt Gingrich (R-GA)

Medicaid covers long-term care, but only for low-income families.  And Medicare only pays for care that is connected to a hospital discharge....our health care system must cover these vital services...[and] we should promote home-based care, which most people prefer, instead of the institutional care that we emphasize now.

Former U.S. Senator Majority Leader Tom Daschle (D-CD)

We need incentives to...keep people in home health care settings...It’s dramatically less expensive than long term care.

U.S. Senator John McCain (R-AZ)


Home care is clearly the wave of the future. It’s clearly where patients want to be cared for. I come from an ethnic family and when a member of our family is severely ill, we would never consider taking them to get institutional care. That’s true of many families for both cultural and financial reasons. If patients have a choice of where they want to be cared for, where it’s done the right way, they choose home.

Donna Shalala, former Secretary of Health and Human Services

A couple of years ago, I spent a little bit of time with the National Association for Home Care & Hospice and its president, Val J. Halamandaris, and I was just blown away. What impressed me so much was that they talked about what they do as opposed to just the strategies of how to deal with Washington or Sacramento or Albany or whatever the case may be. Val is a fanatic about care, and it comes through in every way known to mankind. It comes through in the speakers he invites to their events; it comes through in all the stuff he shares.

Tom Peters, author of In Search of Excellence

Val’s home care organization brings thousands of caregivers together into a dynamic organization that provides them with valuable resources and tools to be even better in their important work. He helps them build self-esteem, which leads to self-motivation.

Mike Vance, former Dean of Disney and author of Think Out of the Box

Val is one of the greatest advocates for seniors in America. He goes beyond the call of duty every time.

Arthur S. Flemming, former Secretary of Health, Education, and Welfare

Val has brought the problems, the challenges, and the opportunities out in the open for everyone to look at. He is a visionary pointing the direction for us. 

Margaret (Peg) Cushman, Professor of Nursing and former President of the Visiting Nurses Association

Although Val has chosen to stay in the background, he deserves much of the credit for what was accomplished both at the U.S. Senate Special Committee on Aging, where he was closely associated with me and at the House Select Committee on Aging, where he was Congressman Claude Pepper’s senior counsel and closest advisor. He put together more hearings on the subject of aging, wrote more reports, drafted more bills, and had more influence on the direction of events than anyone before him or since.

Frank E. Moss, former U.S. Senator

Val’s most important contribution is pulling together all elements of home health care and being able to organize and energize the people involved in the industry.

Frank E. Moss, former U.S. Senator

Anyone working on health care issues in Congress knows the name Val J. Halamandaris.

Kathleen Gardner Cravedi, former Staff Director of the House Select Committee on Aging

Without your untiring support and active participation, the voices of people advocating meaningful and compassionate health care reform may not have been heard by national leaders.

Michael Sullivan, Former Executive Director, Indiana Association for Home Care

All of us have been members of many organizations and NAHC is simply the best there is. NAHC aspires to excellence in every respect; its staff has been repeatedly honored as the best in Washington; the organization lives by the highest values and has demonstrated a passionate interest in the well-being of patients and providers.

Elaine Stephens, Director of Home Care of Steward Home Care/Steward Health Systems and former NAHC C

Home care increasingly is one of the basic building blocks in the developing system of long-term care.  On both economic and recuperative bases, home health care will continue to grow as an essential service for individuals, for families and for the community as a whole.

Former U.S. Senator Olympia Snowe (R-ME)

NCOA is excited to be part of this great event and honored to have such influential award winners in the field of aging.

National Council of Aging

Health care at home…is something we need more of, not less of.  Let us make a commitment to preventive and long-term care.  Let us encourage home care as an alternative to nursing homes and give folks a little help to have their parents there.

Former President Bill Clinton

CMS Proposed FY2016 Hospice Payment Rule Addresses Payment Reform, Aggregate Cap Changes, Diagnoses on Claims

Also signals future plans for public reporting of hospice quality measures
May 1, 2015 02:18 PM

Late Thursday, April 30, the Centers for Medicare & Medicaid Services (CMS) released a proposed hospice payment rule for fiscal year (FY) 2016that addresses payment reform of the routine home care (RHC) level of care by providing a differential payment of two separate rates: one for care provided from day one through day 60 of an episode of hospice care and another for days 61 and after.  In the rule, CMS also provided for a Service Intensity Add-on (SIA) that would be added to RHC payment for RN and social work visits provided during the last seven days of life.  The proposed rule also conveys CMS’ intent to transition the hospice Cap year to the federal fiscal year and implement the alternative method for annual updates to the aggregate Cap mandated by the IMPACT Act, signals CMS’ future intent relative to public reporting of hospice quality data, and clarifies that hospice programs must submit on claims all diagnoses (related or unrelated) of patients under their care.  The National Association for Home Care & Hospice (NAHC) is conducting in-depth analysis of the proposed regulation and its potential impact on hospice programs and the patients they serve.    

Previous information and data released by CMS about its work on payment reform had focused almost exclusively on development of a tiered payment system for RHC and only hinted at the type of approach now being proposed.

“These changes will have far-reaching effects on hospice care and hospice operations, so we need to conduct in-depth analysis to ensure that this first step does not result in negative consequences that could reduce hospices’ ability to deliver comprehensive, high-quality care,” said NAHC President Val J. Halamandaris.  “We are taking a particularly close look at CMS’ proposed service intensity add-on (SIA) that is intended to support the very resource-intensive care provided to patients and families at the end of life.  While we appreciate CMS’ efforts to address this issue, we have concerns about the adequacy of this add-on, and further concerns that CMS would not allow this adjustment for patients residing in nursing facilities.  We must ensure that any payment system changes do not deny these patients equal access to needed services based on their place of residence.”


PAYMENT MODIFICATIONS FOR ROUTINE HOME CARE:  As part of the FY2016 payment rule, CMS is proposing institution of two payment rates for Routine Home Care (RHC) -- one that would be applied for care on days 1 through 60 of a beneficiary’s hospice care, and a reduced rate for RHC delivered beginning on day 61 of the patient’s hospice care.  CMS’s rationale for this approach is that its research has shown that beneficiaries whose entire episode of care is between 8 and 60 days of hospice have higher wage-weighted minute usage than those with longer stays.  Using 60 days for the high RHC rate as opposed to an earlier time assures that hospices would have sufficient resources to provide high quality care to patients whose average daily visit intensity is higher than for longer stay patients.  In order to mitigate potential high rates of admission and discharge in response to the payment rate changes, CMS is proposing that for any patient that is discharged and readmitted to hospice within 60 days of that discharge, his or her prior hospice days will continue to follow the patient and count toward his or her patient days for the receiving hospice.  Worded differently, CMS is proposing that an “episode” of care will be a hospice election period or series of election periods separated by no more than a 60-day gap.  CMS cautions that it will continue to expect that hospices adhere to long-standing policy to provide “virtually all” care during a hospice election. 

PROPOSED SERVICE INTENSITY ADD-ON (SIA) PAYMENT:  While CMS had intensively explored the potential for implementing a tiered payment model, in the rule it indicates that operational concerns and programmatic complexity using a tiered model were prohibitive, and this led the agency to explore the concept of a service-intensity add-on that could be implemented with minimal systems changes and that would limit reprocessing of hospice claims due to sequential billing requirements.  CMS was also concerned that a tiered payment system only addressed skilled services provided in the last 2 days of life.  In order to make a first step toward addressing misalignment of resources in hospice, CMS has opted to establish two RHC payment rates (discussed above) and is also proposing a SIA that would be applied if the following criteria are met:

  1. The day is billed as a RHC level of care day;
  2. The day occurs during the last 7 days of life (and the beneficiary is discharged dead);
  3. Direct patient care is provided by a RN or a social worker that day (in person); and
  4. The service is not provided in a SNF/NF. 

The proposed SIA would be equal to the Continuous Home Care (CHC) hourly payment rate ($38.75 per hour in 2015) multiplied by the amount of direct patient care provided by a RN or social worker for up to 4 hours total per day, as long as the four criteria (above) are met.  This proposed SIA payment would be paid in addition to the current per diem rate for the RHC level of care.  To bill the SIA, CMS would create two separate G-codes to differentiate nursing visits by RNs vs. LPNs.  Relative to billing for the social worker SIA, the social worker would be required to make an in-person visit for the hospice to be eligible for the social-work related SIA.  SNF and NF sites would be excluded as sites from eligibility for the SIA add-on payment.  CMS indicates since the proposed SIA payment would be applicable to any 7-day period of time ending in the patient’s death, hospice elections with short lengths of stay would receive an additional payment that would help mitigate the marginally higher costs associated with short lengths of stay, consistent with the ‘reasonable cost’ structure of the hospice payment system.  CMS believes the SIA helps to address concerns about visit intensity at the end of life and concerns about low profitability of short hospice stays.

Because CMS is required to guarantee budget neutrality in the first year of payment reform, the increased costs associated with SIA payments will be offset by a reduction in the proposed RHC rates.  CMS proposed to maintain a “budget neutral” approach to the SIA payments by adjusting RHC rates on an annual basis, as well.


The FY2016 hospice wage index will be based on the FY2015 hospital pre-floor, pre-reclassified wage index; the proposed payment rule includes several changes that will have an impact on wage index values for FY2016.  CMS will impose the final year of the 7-year phase out of the Budget Neutrality Adjustment Factor (BNAF), which will have an overall impact of MINUS 0.6 percentage points on payment rates.  Additional wage index changes have the impact of further reducing payment rates by MINUS 0.1 percentage points. Additionally, CMS proposes to implement the new labor market delineations based on the 2010 Census:  CMS plans to begin the phase in of the 2010 Core Based Statistical Area (CBSA) wage index values in FY2016 through a blended rate that reflects 50% of the wage index values using the 2000 CBSAs and 50% of the wage index values under the 2010 CBSAs. For FY2017, hospice will fully transition to the 2010 CBSA wage index values.  CMS is using a phased in approach to limit the wide wage index swings that can occur from one year to another when transitioning directly to new CBSA values.    Hospices should note that there are significant changes between the existing labor market delineations and the new delineations that are being phased in, including the addition of new CBSAs, changes in some county designations, and the splitting of some existing CBSAs.

A LINK TO THE PROPOSED HOSPICE WAGE INDEX VALUES FOR FY2016 ARE AVAILABLE ON THE HOSPICE CENTER WEB PAGE AT  in the SPOTLIGHT section. The wage index table provides a crosswalk between the FY2016 wage index using the current OMB delineations in effect in FY2015 and theFY2016 wage index using the proposed revised OMB delineations, as well as the proposed transition wage index values that would be in effect in FY2016 if the proposed changes are finalized.

HOSPICE MARKET BASKET:  The hospice market basket is calculated using the hospital market basket (2.7) as the base, from which is subtracted the ACA-mandated productivity adjustment (projected at 0.6 percentage points for FY2016), and further reduced by 0.3 percentage points by an additional ACA-mandated reduction.   The projected net market basket update for FY2016 is 1.8 percent.

HOSPICE PAYMENT RATES:   The following tables reflect the 2 proposed payment rates for RHC, as well as the proposed FY2016 proposed payment rates for CHC, IRC, and GIP.  These rates would be further reduced in cases where hospices fail to meet the quality reporting requirements applicable to the FY2016 payment update year; the rates also do not take the sequester into account.

Proposed FY 2016 Hospice Payment Rates for RHC (includes budget neutrality adjustment to account for SIA)





Proposed Rates

Proposed SIA budget neutrality factor adjustment (1-0.0081)

Proposed FY 2016 hospice payment update percentage

Proposed FY2016 Payment Rates


Routine Home Care (days 1-60)




X 0.9853

X 1.018

$ 188.20


Routine Home Care (days 61+)




X 0.9967

X 1.018

$ 147.34


Proposed FY2016 Hospice Payment Rates for CHC, IRC, and GIP



Labor Portion


FY2015 Payment Rates

Proposed FY2016 hospice payment update of 1.8 percent

Proposed FY 2016 Payment Rate


Continuous Home Care

Full Rate = 24 hours of care

$=39.44 FY2016 hourly rate




X 1.018

$ 946.65


Inpatient Respite Care




X 1.018

$ 167.78


General Inpatient Care



$ 708.77

X 1.018

$ 721.53


HOSPICE AGGREGATE CAP:  The proposed payment rule outlines plans to modify the cap update, beginning with the 2016 cap year, to reflect the changes included in the IMPACT Act.  That is, the cap update would no longer be calculated using the CPI-U for medical care but rather would be updated by the hospice payment update percentage for the applicable year.  Additionally, CMS is proposing to align the Inpatient and Aggregate Cap accounting years with the federal fiscal year (Oct. 1 through Sept. 30) beginning in federal fiscal year 2017 and thereafter.  As part of this change, CMS would also align the timeframes for counting beneficiaries and payments to the federal fiscal year. CMS further proposed to shift the timeframes for counting days of care for purposes of calculating the inpatient cap to the federal fiscal year. CMS provides a proposed transition plan for shifting these counts to fully comport with the federal fiscal year by 2018 (with 2917 being a transition year).

The 2015 aggregate cap will be $27,135.96; the anticipated 2016 cap is $27,624.41.


HIS Measures

Proposed Policy for Retention of HQRP Measures Adopted for Previous Payment Determination

CMS proposes the following:

  • Beginning with the FY2018 payment determination, once a quality measure is adopted, it will be retained for use in the subsequent fiscal year payment determination unless otherwise stated, i.e. removed, suspended or replaced.

CMS does not propose  to remove any measures for the FY 2017 reporting cycle, nor does it  propose any new measures for FY 2017.  However, CMS is working with the measure development and maintenance contractor to identify measure concepts for future implementation in the HQRP.

Based on input from stakeholders, CMS has identified several high priority concept areas for future measure development:

  • Patient-reported pain outcome measure that incorporates patient and/or proxy report regarding pain management;
  • Claims-based measures focused on care practice patterns including skilled visits in the last days of life, burdensome transitions of care for patients in and out of the hospice benefit, and rates of live discharges from hospice;
  • Responsiveness of hospice to patient and family care needs; and
  • Hospice team communication and care coordination.

CMS invites public comment on this proposal and on  the four high priority concept areas for future measure development.

HIS Form, Manner, and Timing of Quality Data Submission

CMS proposes the following:

  • Modify policies for the timing of new providers to begin reporting to CMS. Beginning with the FY 2018 payment determination and for each subsequent payment determination, CMS proposes that a new hospice be responsible for HQRP quality data reporting beginning on the date they receive their Certification Number (CCN) (also known as the Medicare Provider Number) notification letter from CMS. Under this proposal, hospices would be responsible for reporting quality data on patient admissions beginning on the date they receive their CCN notification.

Currently, new hospices may experience a lag between Medicare certification and receipt of their actual CCN Number. Since hospices cannot submit data to the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system without a valid CCN Number, CMS proposes new hospices begin collecting HIS quality data beginning on the date they receive their CCN notification letter by CMS. CMS believes this will provide sufficient time for new hospices to establish appropriate collection and reporting mechanisms to submit the required quality data to CMS.

CMS invites public comment on the proposal.

HIS Proposed Data Submission Timelines and Compliance Threshold Requirements for FY 2018 Payment Determination and Subsequent Years

CMS proposes the following:

  • Beginning with the FY 2018 payment determination, CMS proposes that hospices must submit all HIS records within 30 days of the Event Date, which is the patient’s admission date for HIS- Admission records or discharge date for HIS-Discharge records.
  • To coincide with this requirement, CMS proposes to establish an incremental threshold for compliance with this timeliness requirement.  The proposed threshold would be implemented over a three-year period and be effective with all HIS admission and discharge records that occur on or after January 1, 2016, in accordance with the following schedule:

Hospices would have to submit no less than 70 percent of their total number of HIS-Admission and HIS- Discharge records by no later than 30 days from the Event Date for the FY 2018 APU determination. The timeliness threshold would be set at 80 percent for FY 2019 and at 90 percent for FY 2020 and subsequent years. The threshold corresponds with the overall amount of HIS records received from each provider that fall within the established 30-day submission timeframes. CMS stated the “ultimate goal is to require all hospices to achieve a timeliness requirement compliance rate of 90 percent or more.”

Proposed Data Submission Timelines and Thresholds

Effective with all HIS admission and discharge records that occur on or after:

Timelines and Thresholds

January 1, 2016 to December 31, 2016

Hospices must submit at least 70 percent for all required HIS records within the 30 day submission timeframe for the year or be subject to a 2 percentage point reduction to their market basket update for FY 2018.

January 1, 2017 to December 31, 2017

Hospices must score at least 80 percent for all HIS records received within the 30 day submission timeframe for the year or be subject to a 2 percentage point reduction to their market basket update for FY 2019.

January 1, 2018 to December 31, 2018

Hospices must score at least 90 percent for all HIS records received within the 30 day submission timeframe for the year or be subject to a 2 percentage point reduction to their market basket update for FY 2020.


Hospice CAHPS Participation Requirements for the 2018 APU and 2019 APU

CMS Comment Only:  Consistent with many other CMS CAHPS® surveys that are publicly reported on CMS Web sites, CMS will publicly report hospice data when at least 12 months of data are available, so that valid comparisons can be made across hospice providers in the United States, to help patients, family and friends choose a hospice program for themselves or their loved ones.

Hospice CAHPS Participation Requirements to Meet Quality Reporting Requirements for the FY 2018 APU

CMS proposes the following:

To comply with CMS's quality reporting requirements for the FY 2018 APU, hospices will be required to collect data using the CAHPS® Hospice Survey. Hospices would be able to comply by utilizing only CMS-approved third party vendors that are in compliance with the provisions at §418.312(e). Ongoing monthly participation in the survey is required January 1, 2016 through December 31, 2016 for compliance with the FY 2018 APU.

To meet the HQRP requirements for the FY 2019 payment determination, hospices would collect survey data on a monthly basis for the months of January 1, 2017 through December 31, 2017 to qualify for the full APU. A summary table is below.

CAHPS® Hospice Survey Data Submission Dates FY2017 APU, FY2018 APU, and FY2019 APU

Sample Months
(that is, month of death)1

Quarterly data
submission deadlines2

FY2017 APU


Dry Run January-March 2015 (Q1)

August 12, 2015

April-June 2015 (Q2)

November 11, 2015

July-September 2015 (Q3)

February 10, 2016

October-December 2015 (Q4)

May 11, 2016

FY2018 APU


January-March 2016 (Q1)

August 10, 2016

April-June 2016 (Q2)

November 9, 2016

July-September 2016 (Q3)

February 8, 2017

October-December 2016 (Q4)

May 10, 2017

FY2019 APU


January-March 2017 (Q1)

August 9, 2017

April-June 2017 (Q2)

November 8, 2017

July-September 2017 (Q3)

February, 14, 2018

October-December 2017 (Q4)

May 9, 2018


1=Data collection for each sample month initiates two months following the month of patient death (for example, in April for deaths occurring in January).
2=Data submission deadlines are the second Wednesday of the submission month.
3=Corrected from the Final Rule published August 22, 2014, 79 FR 50493.

CMS proposes to continue the exemption for very small hospices from CAHPS® Hospice Survey requirements: hospices that have fewer than 50 survey-eligible decedents/caregivers in the period from January 1, 2015 through December 31, 2015 are exempt from CAHPS® Hospice Survey data collection and reporting requirements for the 2018 APU. To qualify for the survey exemption for the FY 2018 APU, hospices must submit an exemption request form. This form will be available on the CAHPS® Hospice Survey Web site   Hospices are required to submit to CMS their total unique patient count for the period of January 1, 2015 through December 31, 2015. The due date for submitting the exemption request form for the FY 2018 APU is August 10, 2016.

CAHPS® Hospice Survey Oversight Activities

CMS proposes the following:

  • Continue a requirement that vendors and hospice providers participate in CAHPS® Hospice Survey oversight activities to ensure compliance with Hospice CAHPS® technical specifications and survey requirements. The purpose of the oversight activities is to ensure that hospices and approved survey vendors follow the CAHPS® Hospice Survey technical specifications and thereby ensure the comparability of CAHPS® Hospice Survey data across hospices.
  • The reconsiderations and appeals process for hospices failing to meet the Hospice CAHPS® data collection requirements will be part of the Reconsideration and Appeals process already developed for the Hospice Quality Reporting Program.
  • Additions to the communications method regarding annual notification of reporting compliance in the HQRP.  In the past, only hospices found to be non-compliant with the reporting requirements set forth for a given payment determination received a notification of this finding along with instructions for requesting reconsideration in the form of a certified United States Postal Service (USPS) letter. In addition to sending a letter via regular USPS mail, beginning with the FY 2017 payment determination and for subsequent fiscal years, CMS proposes to use the Quality Improvement and Evaluation System (QIES) National System for Certification and Survey Provider Enhanced Reports (CASPER).  The electronic APU letters would be accessed using the CASPER Reporting Application. Additional information about how to access the letters would be provided prior to the release of the letters.
  • Disseminate communications regarding the availability of hospice compliance reports in CASPER files through routine channels to hospices and vendors, including, but not limited to issuing memos, emails, Medicare Learning Network (MLN) announcements, and notices on
  • Propose to publish a list of hospices who successfully meet the reporting requirements for the applicable payment determination on the HQRP website. CMS further proposed updating the list after reconsideration requests are processed on an annual basis.

CMS invites comment on the proposals to add CASPER Reporting as an additional communication mechanism for the dissemination of compliance notifications and to publish a list of compliant hospices on the HQRP website.

Public Display of Quality Measures and other Hospice Data for the HQRP

CMS made no proposal but did provide comments on the public display of HQRP data.  CMS stated: “We believe it is critical to establish the reliability and validity of the quality measures prior to public reporting in order to demonstrate the ability of the quality measures to distinguish the quality of services provided. To establish reliability and validity of the quality measures, at least four quarters of data will be analyzed.  We began data collection in CY 2014; the data from CY 2014 for Quarter 3 (Q3) will not be used for assessing validity and reliability of the quality measures. We are analyzing data collected by hospices during Quarter 4 (Q4) CY 2014 and Q1–Q3 CY 2015. Decisions about whether to report some or all of the quality measures publicly will be based on the findings of analysis of the CY 2015 data.”

A timeline for posting hospice data on a public data set has not been determined by CMS. Should a timeline become available prior to the next annual rulemaking cycle, details would be announced via regular HQRP communication channels, including listening sessions, memos, email notification, and Web postings.

CMS did indicate it will develop a CMS Compare Web site for hospice, which will list hospice providers geographically. Like other CMS Compare Web sites, the Hospice Compare Web site will feature a quality rating system that gives each hospice a rating of between one (1) and five (5) stars. Hospices will have prepublication access to their own agency’s quality data, which enables each agency to know how it is performing before public posting of data on the Compare Web site. Decisions regarding how the rating system will determine a provider’s star rating and methods used for calculations, as well as a proposed timeline for implementation, will be announced via regular HQRP communication channels, including listening sessions, memos, email notification, provider association calls, Open Door Forums, and Web postings. CMS will announce the timeline for public reporting of quality measure data in future rulemaking.

Diagnosis Reporting on Hospice Claims:  CMS commented that it is concerned that some hospices are making determinations of hospice coverage based solely on cost and reimbursement as opposed to being based on patient-centered needs, preferences and goals for those approaching the end of life. CMS believes this to be counter to the holistic, comprehensive, and coordinated hospice care model promoted during the development of the Medicare hospice benefit.  CMS stated it was very clear throughout the development, and years after the implementation, of the Medicare hospice benefit that hospices were expected to make good on their promise to do a better job in the provision and coordination of care than conventional Medicare for those who were at the end of life.  However, if hospices are not making good on that promise, it results in increased burden on hospice beneficiaries and their families— both clinically and financially—and is not in keeping with the intent of the Medicare hospice benefit as originally developed and implemented in 1983.

Clarification Regarding Diagnosis Reporting on Hospice Claims

CMS clarified that hospices will report all diagnoses identified in the initial and comprehensive assessments on hospice claims, whether related or unrelated to the terminal prognosis of the individual. This is in keeping with the requirements of determining whether an individual is terminally ill. This would also include the reporting of any mental health disorders and conditions that would affect the plan of care as hospices are to assess and provide care for identified psychosocial and emotional needs, as well as, for the physical and spiritual needs.  CMS will monitor compliance with required coding practices and collaborate with all relevant CMS components to determine whether further policy changes are needed or if additional program integrity oversight actions need to be implemented.

Based on the numerous comments received in previous rulemaking, and anecdotal reports from hospices, hospice beneficiaries, and non- hospice providers discussed above, CMS is concerned that hospices may not be conducting a comprehensive assessment nor updating the plan of care as articulated by the Conditions of Participation to recognize the conditions that affect an individual’s terminal prognosis.

ICD-10-CM Coding Guidelines state that diagnoses should be reported that develop subsequently, coexist or affect the treatment of the individual. Furthermore, having these diagnoses reported on claims falls under the authority of the Affordable Care Act for the collection of data to inform hospice payment reform.

Having adequate data on hospice patient characteristics will help to inform thoughtful, appropriate, and clinically relevant policy for future rulemaking. We will monitor compliance with required coding practices and collaborate with all relevant CMS components to determine whether further policy changes are needed or if additional program integrity oversight actions need to be implemented.

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10- CM) Coding Guidelines state the following regarding the selection of the principal diagnosis: The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. In the case of selection of a principal diagnosis for hospice care, this would mean the diagnosis most contributory to the terminal prognosis of the individual. In the instance where two or more diagnoses equally meet the criteria for principal diagnosis, ICD- 10-CM coding guidelines do not provide sequencing direction, and thus, any one of the diagnoses may be sequenced first, meaning to report all of those diagnoses meeting the criteria as a principal diagnosis. Per ICD-10-CM Coding Guidelines, for diagnosis reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring:

  • Clinical evaluation; or
  • Therapeutic treatment; or
  • Diagnostic procedures; or
  • Extended length of hospital stay; or
  • Increased nursing care and/or monitoring

The UHDDS item #11-b defines Other Diagnoses as all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. ICD-10-CM coding guidelines are clear that all diagnoses affecting the management and treatment of the individual within the healthcare setting are requirement to be reported. This has been longstanding existing policy. Adherence to coding guidelines when assigning ICD-9-CM and ICD-10-CM diagnosis and procedure codes is required under the Health Insurance Portability and Accountability Act (HIPAA) as well as regulations at 45 CFR 162.1002.

NAHC will continue to analyze the FY2016 hospice proposed payment rule and provide updates in future issues of NAHC Report and on its member listservs.




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