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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

NAHC Outlines Planned Comments on Hospice FY2016 Proposed Payment Rule

Stakeholders Urged to Submit Individual Comments to CMS by June 29, 2015
June 25, 2015 08:43 AM

On April 30, 2015, the Centers for Medicare & Medicaid Services (CMS) released Medicare Program; FY2016 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements; Proposed Rule” (CMS-1629-P), which puts forth CMS’ proposals for changes to the hospice payment and quality reporting programs and provides a clarification related to inclusion of diagnosis codes on hospice claims. Following is a table outlining key points the National Association for Home Care & Hospice (NAHC) intends to include as part of its comments to CMS on the proposed rule. NAHC members are encouraged to review the outline and incorporate any elements in their own comments on the proposed rule if they see fit. To be assured formal consideration as part of the formal rulemaking process, comments must be submitted by 5 p.m. on June 29, 2015. Comment submissions must include reference to CMS-1629-P and arrive by the comment deadline. NAHC recommends submission of comments in one of the following ways:

Electronically. You may submit electronic comments on this regulation to Follow the “Submit a comment” instructions.

By regular mail. You may mail written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1629-P, P.O. Box 8010, Baltimore, MD 21244-8010. Please allow sufficient time for mailed comments to be received before the close of the comment period.

By express or overnight mail. You may send written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1629-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

Payment Reform -- Data Analyses

CMS provides a significant amount of data and analyses related to its research on hospice care patterns and spending outside of hospice for hospice-enrolled beneficiaries.
NAHC believes that data CMS has provided as part of the FY2016 proposed rule (and previous analyses that have been made public) raise concerns about the incidence of unbundling of elements of care that are appropriately part of the hospice benefit. We encourage CMS’ continuing efforts to review patterns of practice that raise concerns about the potential for unbundling of the benefit.

A significant portion of inappropriate billing outside the hospice benefit are due to antiquated CMS systems that do not provide timely access to patient status relative to hospice election. NAHC urges that CMS take long-needed action to update its systems to allow more timely access to patient status information and allow for better coordination of patient care.

NAHC also recommends additional efforts by CMS to educate providers outside of hospice on the interaction of the hospice benefit with other Medicare coverages. We urge that CMS examine and address potential conflicts or inconsistencies between hospice requirements and policies related to coverage/billing outside of the hospice benefit.

NAHC cautions CMS against any blanket determination that all care provided to hospice patients is the responsibility of the hospice. This is a determination that must be made on a case-by-case basis by individuals trained in end of life care. Any efforts to place the responsibility for all care with the hospice -- regardless of whether it is related or unrelated to the diagnoses that make up the hospice prognosis -- is in conflict with existing law that preserves a beneficiary’s right to care outside of hospice for non-related conditions. If CMS contemplates the shifting of clinical and financial responsibility for unrelated conditions to hospice providers, such action must be accompanied by open discussion of CMS’ plans, collection of more accurate cost data and modifications to the hospice payment system to reflect the increased care responsibilities to ensure that financial stability and access to care may be maintained.

NAHC is concerned that CMS has not released the 2015 technical report that was developed to accompany the proposed hospice payment changes:
the proposed rule does not provide sufficient data to permit a thorough analysis of calculations related to the payment changes; and
CMS does not provide data related to payment reform alternatives that CMS considered and rejected.
NAHC urges release of the technical report at the earliest possible opportunity to permit hospice stakeholders a better understanding of CMS’ calculations and policy decisions, as well as the impact of alternatives that CMS considered.
Payment Reform -- RHC Payment Rates

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 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.
NAHC supports CMS’ approach to defining an episode of hospice care, and recognizes the need to include a hospice care gap that would signal the start of a new episode of care. We also recognize that this gap could have a negative impact on hospices that accept patients onto care as transfers, and will comment further in the SIA section.

NAHC urges CMS to conduct ongoing analysis of the adequacy of the payment changes with particular attention to the overall impact on those hospices that provide care predominantly to patients with short lengths of stay.

As referenced previously, hospices and other providers currently are not guaranteed accurate patient status information relative to previous hospice elections; this information is vital when accepting patients onto service to ensure prudent budgeting and planning. This underscores the need for CMS systems changes that allow for ready access to accurate information on patient status.
Payment Reform -- Service Intensity Add-on (SIA)

Proposing implementation of a Service Intensity Add-on (SIA) that would be applied if the following criteria are met:
  • The day is billed as a RHC level of care day;
  • The day occurs during the last 7 days of life (and the beneficiary is discharged dead);
  • Direct patient care is provided by a RN or a social worker that day (in person); and
  • The service is not provided in a SNF/NF.
The proposed SIA would be equal to the Continuous Home Care (CHC) hourly payment rate 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.
NAHC appreciates CMS’ recognition of increased service use intensity in the final days of life as evidenced by the SIA.

NAHC strongly objects to CMS’ plans to prohibit payment of the SIA for patients in NF/SNF. This policy creates unfair and negative incentives that could limit equal access to service for patients who reside in facilities.

The SIA payment is based on the CHC hourly rate, but is limited to only RN and Social Worker visits. CHC payments are currently permitted for nursing services provided by RNs or LPNs/LVNs; a portion of CHC services may be provided by hospice aides, as well. CHC payments may average out so that they cover a hospice’s costs in providing care, but the SIA payment is unlikely to do so -- in many areas of the country the hourly rate for RN services exceeds the hourly CHC rate. Additionally, we have concerns that hospices in rural areas and in areas with health professional shortages may not have sufficient RNs available to allow them to be reimbursed for the SIA. For these reasons, NAHC believes visits by LPNs/LVNs should be included as reimbursable as an SIA service.

NAHC encourages CMS to provide additional information about how RN services were distinguished from LPN/LVN services for purposes of estimating SIA expenditures; this information was not provided in the proposed rule.

We would encourage CMS to begin collection of data related to chaplain services and consider possible inclusion of chaplain visits in the SIA as part of future changes as these are services that are in additional demand during the final days of life.

NAHC appreciates that CMS gave consideration to provision of an SIA-type payment on the first two days of service when a patient changes hospice providers but understand that CMS opted against this policy. We would urge continuing study of this issue with an eye toward possible future changes along these lines.
Payment Reform Implementation Issues NAHC believes that the many outstanding questions; the complexities associated with institution of a new payment system for CMS, Medicaid programs, vendors and providers alike; and the limited time frame between publication of a final rule and the beginning of the federal fiscal year provide insufficient time to ensure a smooth transition to a new payment system by Oct. 1, 2015. For these and other reasons, we urge that CMS only implement the new payment system after it is able to implement systems changes and allow for a dry run to ensure that CMS, state Medicaid programs, MACs, vendors and providers are all ready for the new system. This may require starting the new system in January or April of 2016, or even a bit later.

CMS has not indicated whether the new payment rates will apply across the board to all patients on service when the new system is instituted or only to new admissions. To allow for appropriate financial planning by hospices, NAHC recommends that CMS apply the new payment system to new hospice admissions. Care for patients already on service would continue to be paid under the current hospice payment model.

NAHC requests that CMS clarify that the appropriate RHC rate would be determined by the day count within the episode of care regardless of whether the patient has been served at another level of care during the time period.

NAHC urges CMS to provide some clarification in the final rule as to whether the appropriate RHC rates will be determined by CMS systems (as opposed to the provider being required to bill at the appropriate rate). Additionally, it would be helpful in the final rule if CMS could provide more detail about how the SIA payments will be addressed within CMS systems.

Given institution of a two-tiered payment system for RHC, we would ask that CMS clarify how CMS and the MACs will determine which RHC payment rate will be applicable when a hospice exceeds the General Inpatient Cap and the rate is reduced to the RHC rate.
Aggregate Cap Update

Aggregate 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.
This reflects a legislative change required by the IMPACT Act. No comment.
Align Cap Years with Federal Fiscal Year

Align the Inpatient and Aggregate Cap accounting years with the federal fiscal year 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 2017 being a transition year).
NAHC supports full alignment of the hospice cap year with the federal fiscal year. We encourage CMS to direct the MACs to provide timely notice of forthcoming changes so that hospices can adequately track their cap status as well as to minimize confusion when hospice providers calculate and self-report their aggregate cap.
Hospice Quality Reporting Program (HQRP)-- General NAHC understands and appreciates the time necessary to establish the reliability and validity of the data and look forward to the release of the finalized algorithms for measure calculations.
Retention of HQRP Measures in Use No comment.
Removal of HQRP Measures

Quality measures may be considered for removal by CMS if:
  • Measure performance among hospices is so high and unvarying that meaningful distinctions in improvements in performance can be no longer be made;
  • Performance or improvement on a measure does not result in better patient outcomes;
  • A measure does not align with current clinical guidelines or practice;
  • A more broadly applicable measure (across settings, populations, or conditions) for the particular topic is available;
  • A measure that is more proximal in time to desired patient outcomes for the particular topic is available;
  • A measure that is more strongly associated with desired patient outcomes for the particular topic is available; or
  • Collection or public reporting of a measure leads to negative unintended consequences.
For any such removal, the public will be given an opportunity to comment through the annual rulemaking process. However, if there is reason to believe continued collection of a measure raises potential safety concerns, CMS will take immediate action to remove the measure from the HQRP and will not wait for the annual rulemaking cycle.
We appreciate CMS’ proposal that for removal of any HQRP measures, the public will be given an opportunity to comment through the annual rulemaking process, and we encourage the same approach for inclusion of any new measures as part of the HQRP. The proposed reasons for removal of a measure are reasonable and NAHC supports these reasons.
Priority Areas for Future Hospice Quality Measures

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;
  • Hospice team communication and care coordination
We understand the concerns that prompted the focus on these areas as priority areas for future measures.

Relative to CMS’ interest in considering claims-based measures focused on care practice patterns, NAHC cautions that any claims-based measure utilized in the HQRP must be properly vetted to ensure that the measures is directly related to quality of hospice care. Otherwise, the public will draw limited benefit from these measures and could interpret their meaning relative to a particular hospice incorrectly.

NAHC reminds CMS that any measures that are part of the HQRP must be: “… endorsed by the consensus-based entity, which holds a contract regarding performance measurement with the Secretary under section 1890(a) of the Act” or, in cases of measures not endorsed by the entity, the Secretary must ensure that due consideration has been given to endorsed measures. Use of clams-based measures that have not been endorsed must meet CMS’ paramount concern that “…successful development of a Hospice Quality Reporting Program (HQRP) that promotes the delivery of high quality healthcare services.”

In considering potential claims-based measures referenced in the proposed rule, we are concerned that in their current state they do not meet the above requirements and, in fact, may fall within some of the proposed reasons for elimination from the HQRP, specifically:
  • Performance or improvement on a measure does not result in better patient outcomes;
  • Collection or public reporting of a measure leads to negative unintended consequences.
As stated previously, NAHC understands CMS’ and others’ interest in claims-based measures but believe they are more appropriately viewed as practice indicators as opposed to quality indicators.  A claims-based measure should not be used in the HQRP unless its direct relationship to hospice quality has been proven.

New Hospices -- Reporting Requirements

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.

This change will be helpful to new hospice providers as generally they do not receive their CCN (Medicare Provider Number) until some time after they have been formally certified.

HIS Record Submission Requirements

Beginning with the FY 2018 payment determination, CMS proposes that hospices must submit all HIS records within 30 days of the Event Date. The Event Date is the patient’s admission date for HIS-Admission records or discharge date for HIS-Discharge records.

NAHC agrees with this proposal
HQRP Exception/Extension Requirements

Allow hospices to request and for CMS to grant exemptions/extensions with respect to the reporting of required quality data when there are extraordinary circumstances beyond the control of the provider. When an extension/exception is granted, a hospice will not incur payment reduction penalties for failure to comply with the requirements of the HQRP. For the FY 2016 payment determination and subsequent payment determinations, a hospice may request an extension/exception of the requirement to submit quality data for a specified time period (see below). In the event that a hospice requests an extension/exception for quality reporting purposes, the hospice would submit a written request to CMS. In general, exceptions and extensions will not be granted for hospice vendor issues, fatal error messages preventing record submission, or staff error.
In the event that a hospice seeks to request an exception or extension for quality reporting purposes, the hospice must request an exception or extension within 30 days of the date that the extraordinary circumstances occurred by submitting the request to CMS via email to the HQRP mailbox at Exception or extension requests sent to CMS through any other channel would not be considered as a valid request for an exception or extension from the HQRP’s reporting requirements for any payment determination. In order to be considered, a request for an exception or extension must contain all of the finalized requirements as outlined at Instruments/HospiceQuality-Reporting/index.html.
If a provider is granted an exception or extension, timeframes for which an exception or extension is granted will be applied to the new timeliness requirement so providers are not penalized. If a hospice is granted an exception, CMS will not require that the hospice submit any quality data for a given period of time. If CMS grants an extension to a hospice, the hospice will still remain responsible for submitting quality data collected during the timeframe in question, although CMS will specify a revised deadline by which the hospice must submit this quality data.

This process does not preclude CMS from granting extensions/exceptions to hospices that have not requested them when CMS determines that an extraordinary circumstance exists for an entire region or locale. CMS may grant an extension/exception to a hospice if it determines that a systemic problem with the CMS data collection systems directly affected the ability of the hospice to submit data. If CMS makes such a determination to grant an extension/exception to hospices in a region or locale, CMS will communicate this decision through routine communication channels to hospices and vendors, including, but not limited to, Open Door Forums, ENews and notices on Assessment-Instruments/Hospice-Quality-Reporting/.
Hospices have reported that there have been instances when they would not have been able to email CMS within 30 days, i.e. Storm Sandy on the East Coast, Hurricane Katrina, etc. Therefore, NAHC urges CMS to be able to accept email, mail, and verbal requests from providers OR to extend the number of days required for submission to 90.
Threshold for Timeliness Requirements

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.
NAHC agrees with this incremental threshold. Many hospices have reported that they would not anticipate this being a problem for them. Furthermore, CMS is proposing an exemption/extension process that would afford any hospice not being able to meet the 30-day deadline an opportunity to avoid the 2% penalty in certain situations. The proposed process is reasonable and supported by NAHC. We expect that CMS will be closely monitoring hospices’ progress in meeting the timeliness thresholds over time and conduct provider outreach and education if certain providers have particular difficulty in meeting the thresholds.
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 nstruments/Hospice-Quality-Reporting/Reconsideration-Requests.html
  • 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.
NAHC supports the proposal related to the Hospice CAHPS Survey oversight activities.
Reporting of Diagnoses 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.
CMS clarifies in the proposal that hospices are to include all of a patient’s diagnoses on the hospice claim. Because it is a clarification, it appears that CMS may want hospices to comply with this clarification now. Considering that the compliance with the clarification would mean non-compliance with what is required under the FY2015 final rule, we urge CMS to not hold hospices accountable for including all diagnoses on hospice claims unless such clarification is made part of the final rule with a future effective date.

In comments made by CMS in the proposed rule, CMS indicates that hospices may not be conducting thorough assessments of hospice patients because all of a patient’s diagnoses are not listed in the patient’s medical record.  There are instances where hospices are not aware of all of a patient’s previous diagnoses because the hospice has not received all of the patient’s medical history. A hospice is limited to the medical history shared by the patient/family and information from other providers to which hospice has access.

In addition, diagnoses are sometimes historical and not impacting the patient plan of care. Those diagnoses not impacting the plan of care would not be included in the plan of care and, therefore, may not be included on the claim. Exclusion of historical diagnoses that are not pertinent to the plan of care is consistent across provider types and should not negatively impact the hospice provider. Requiring hospices to ensure inclusion of non-pertinent diagnoses in the medical record and on the claim is not beneficial to the patient and only distracts the hospice IDG from providing the care that is necessary for the relevant diagnoses.

There is concern with the software systems allowing enough space on the claim for all diagnoses to be listed. And, we understand, there is a limit of 17 diagnoses for electronic claims submission. While not the norm, there may be some patients who have more than 17 diagnoses. Also, there is the question of whether CMS will now, or at some point in the future, expect hospice providers to identify which of the diagnoses on the claim are related. There currently is not a mechanism for doing this on the claim. If hospices will be required to submit all diagnoses on the hospice claim, we believe it is advisable that the diagnoses be differentiated between related and unrelated. Vendors will need time to not only create the technical specifications for inclusion of all diagnoses, but if those diagnoses are to be differentiated, vendors will need to incorporate this as well. Implementing this type of change at the same time a hospice is implementing ICD-10 creates an environment for more mistakes to be made and for inaccurate data to be provided to CMS via the claim. These adjustments are also both labor-intensive, and concurrent implementation will place significant strains on hospice personnel.

While we recognize that coding guidelines indicate that all of a patient’s diagnoses should be included on claims for services, it would be helpful if CMS could provide additional information as to its goals in putting forth this clarification at this time-- including CMS’ plans for use of all of the diagnoses on the claims and whether it is CMS’ intent to hold hospices accountable for paying for and managing all care related to all diagnoses provided on the claim.





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