2014 PPE Disclosure Statement It is the policy of the Oregon Hospice Association to insure balance, independence, objectivity, and scientific rigor in all its educational programs. All faculty participating in any Oregon Hospice Association program is expected to disclose to the program audience any real or apparent affiliation(s) that may have a direct bearing on the subject matter of the continuing education program. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker from making a presentation. It is merely intended that any relationships should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. This presenter discloses these relationships: Salix Pharm – speakers bureau and scientific advisory board; Grant Funding – AHRQ, CMMI, NINR, The Duke Endowment: Aspire Health – Senior Medical Advisor 1

Diagnosis Dilemmas and Medication Issues Janet Bull, MD FAAHPM Four Seasons CMO

Objectives o Describe coding issues with debility, failure to thrive, and dementia o Develop competency by examining case studies o Review elements of ICD-9 CM coding guidelines o Discuss attending of record o Understand Part D requirements

What’s the Buzz? o 2015 Final Rule – Wage Index Report Issues with Diagnosis Attending of Record Changes Related vs Unrelated Hospice Item Set – Quality Reporting Changes to Notice of Election Update on payment reform Federal Registry 8/22/ /pdf/ pdf

Diagnosis on Hospice Claims o Clarification of existing guidelines o 2014 Wage Index report – “we provided in-depth information regarding longstanding, existing ICD-9 coding guidelines.” o CMS looked at 1 st Quarter – 72% hospice claims had one diagnosis

Secondary Diagnosis Wanted! 67% all claims Only report primary diagnosis “The reporting of only one principal diagnosis does not lend to a comprehensive, holistic, and accurate description of the beneficiaries’ end-of-life conditions and may not fully reflect the individualized needs in the individual’s required hospice plan of care.” FY 2013 Data

Secondary Diagnosis o Paper UC-04 claim – allows 17 dx o electronic claim – 24 dx o CMS expects hospices to use secondary dx If you are not using secondary diagnosis, need to start!

Use of Nonspecific Symptom Codes o Cannot use any “ill defined diagnosis” as a principle diagnosis ( ) o Can no longer use debility and FTT - MACs will soon be instructed to return claims for more definitive diagnosis, RTP by Oct 1, 2014 o ICD-9-CM does not allow use of nonspecific codes as principal diagnosis

Top Ten Principal Hospice Dx Source: FY 2002, 2007, 2012 and 2013 hospice claims data from the Chronic Condition Warehouse (CCW). 9%

Debility & Failure to Thrive Source: FY 2002, 2007, 2012 and 2013 hospice claims data from the Chronic Condition Warehouse (CCW).

Debility and FTT o Lack information regarding clinical condition o Need more definitive diagnosis Final Rule 8/22/14

Medicare Claims with Debility/FTT o 50% had ≥ 7 chronic conditions o 75% had ≥ 4 chronic conditions o Chronic Condition Data Warehouse

Debility/FTT Claims – no secondary dx 2012 chronic conditions warehouse

Dementia – What’s the Issue?

Dementia o Issue relates to inappropriate coding o Alzheimer’s o Senile – o Vascular – o Follow ICD 9 codes for diagnosis and sequencing rules. Do not use manifestation codes – “in diseases classified elsewhere”

Manifestation Codes o Manifestations are characteristics, signs or symptoms of an illness. When one disease or condition causes another disease or condition, the one that caused it is the etiology and the resulting second condition is the manifestation. o Manifestation codes cannot be principal diagnosis

Other Dementias Medical Codes Senile degeneration of the brain – Frontotemporal dementia – Dementia with Lewy Body – Late effects of CVD – 438 Psychiatric Codes Senile dementia – 290 Dementia with behaviors – Senile dementia with delusions –

Case #1 80 yo WM in SNF Hypertension, diabetes, dementia, peripheral Neuropathy, CAD, CHF – NYHA III, hypothyroid 2 pound weight loss over 2 months, dysphagia, oxygen at night, B/B incontinence Hospitalized 3 mo ago with CHF, BNP 1856 Fast 6e, BMI 19.8, PPS 40%, 5/6 ADLs BNP – 427, Cr 1.8, Hgb 11 Meds metoprolol, lisinopril, gabapentin, synthroid acetaminophen, insulin, donepezil, atorvastatin Admit or not?

Is this someone we would have put in under debility or FTT? Do they meet a LCD or Prognostic Indicator?

So you decide to admit… A. Dementia B. Congestive heart failure C. Other? How do you decide? Use best evidence guidelines and clinical judgment

Dementia – Mortality Risk Index Complete dependence with ADLs1.9 Male Gender1.9 Cancer1.7 CHF1.6 Oxygen therapy past 14 days1.6 SOB1.5 <25% po intake1.5 Unstable medical condition1.5 Bowel incontinence1.5 Bedfast1.5 Age > 83 yo1.4 Sleeps most of the day1.4 ✓ ✓ ✓ ✓ ✓ Total 8.1

Mortality Risk Index Risk of estimate of death in 6 months o 0 pts8.9 % o % o % o %  o % o > % Mitchell, SL, JAMA 2004, vol 291,

Prognosis in Dementia o FAST 7c 39.5 % mortality in 6 mo (poor selectivity) 22.2% who died had FAST 7c (poor sensitivity) Excluded a substantial portion of patients who died in 6 months – 77.8%

Other Supporting Dementia Dx o Dysphagia – risk of Aspiration o Weight loss o PPS of 40% o Coexisting CHF o Failure to thrive

Congestive Heart Failure o Supporting documentation Maximally treated on meds Oxygen Hyponatremia Anemia Cachexia, FTT Poor functional status SOB Previous hospitalization with high BNP Coexisting renal disease

Is there a ICD-9 CM code for end stage cardiac disease?

Need to dig a little deeper…. o Possible options include CHF Cardiomyopathy Ischemic heart disease Cor pulmonale Chronic pulmonary heart disease Acute myocarditis – 422 Valvular disease – 424 Cardiac dysarrythemia – 427 o All other contributing diagnosis on claim form

Choosing Diagnosis “It is often not a single diagnosis that represents the terminal illness of the patient, but the combined effect of several conditions that makes the patient’s condition terminal.”

Secondary Diagnosis/Meds o CHF or dementia (depending on principal) o What about these? CAD Hypertension Diabetes, Peripheral Neuropathy o Which meds do you cover? Metoprolol, lisinopril, gabapentin, synthroid acetaminophen, insulin, donepezil, atorvastatin

Example of certification…. 80 yo white male with primary diagnosis of cerebral atherosclerosis (437)*. Secondary diagnosis include vascular dementia (290.4),CHF(428), CAD (414.01), hypertension (401.9), and peripheral neuropathy (443.9), and FTT (783.41). Maximally treated with cardiac meds, on oxygen at 2 L/min at night, and c/o dyspnea with minimal exertion. PPS 40%, BMI is 19.8, with 2 pound weight loss in past 2 months. FAST 6e, BNP – 437, Cr 1.8, Hgb 11, Sodium 130. * Codes not needed in certification

Do not include comorbidities that do not contribute to the terminal prognosis in the narrative!

Let’s look at a tougher case.. 94 yo WF with mild dementia, osteoporosis, and hypothyroidism. She has been to the ER for falls x 3, sustained a wrist fracture. PPS 60 to 40%, weight loss of 10 pounds with BMI of 19. Only eating 20%, 3/6 ADLs. Do you admit? If so, diagnosis, principal dx? Secondary dx?

Choose the best diagnosis o Principal Dx – Osteoporosis o Secondary Dx – Wrist fracture, FTT o What about Dementia? Hypothryoidism? This question was posed to one of the MACS who confirmed osteoporosis as principal dx

What if only diagnosis ill-defined? 77 year old patient with dysphagia, decreased oral intake, malnutrition with albumin of 2.1, weight loss 10 pounds in 6 weeks with BMI of PPS 60 to 30% in 1 month timeframe. No underlying diagnoses or comorbidities. Doesn’t want to return to ER or hospital. Prognosis determined by physician to be < 6 months.

How to Code? o Malnutrition – o Dysphagia – o Muscle weakness – This example given in the Final Rule. Only use ill defined if NO other principal diagnosis relevant

Example of Certification 77 yo WF with principal diagnosis of protein calorie malnutrition (263.9)* and related diagnosis of and failure to thrive (783.7), weight loss, (783.21) and dysphagia. ( ) No other comorbidities. PPS has declined from 60% to 30%, and now dependent on all ADLs. Refuses further hospitalizations or ER, with goals focused on comfort care. * Codes not needed

Coding Guidelines o Malnutrition o Abnormal weight loss “ According to ICD 9 Coding Guidelines, codes that fall under the classification “Symptoms, Signs, and other Ill-defined Conditions”, such as “debility” and “adult failure to thrive”, can only be used as a principal diagnosis when a related definitive diagnosis has not been established or confirmed by the provider.” Answer to question posed in Final Rule

But wait! – haven’t the MACs encouraged use of FTT/Debility? o Palmetto MAC – specific LCD on FTT o Furthermore they state In the event a beneficiary presenting with a nutritional impairment and disability does not meet the medical criteria listed above, but is still thought to be eligible for the Medicare Hospice Benefit, an alternate diagnosis that best describes the clinical circumstances of the individual beneficiary should be selected (e.g "abnormal loss of weight" and "Cachexia”)

What about NGS? o Decline in clinical status o PPS <70% 2/6 ADL dependence o NGS - Contractors will not make any changes to the edits until we receive direction from CMS in the form of the Change Release Published: May 30, 2013

Proper Coding o To ensure compliance Implement edits from Medicare Code Editor (MCE) which detect and report errors Certain codes plugged in to MCE Effective 10/1/2014 Inappropriate codes – RTP (Return to Provider)

Specific Codes NOT to use o 290 – Dementia codes o Delirium o 310 – Organic brain syndrome

New Patient Admissions o Avoid ill defined primary diagnosis if at all possible o Use LCDs for guidance o Include ALL diagnosis affecting prognosis on claim form and in narrative o Medication profile may be helpful in determining diagnosis o Narratives should reflect WHY you are admitting this patient. If patient does not meet LCDs then explain what is causing the < 6 month prognosis

Existing Debility/FTT Patients o Physician – review plan of care and note affected bodily systems, symptoms, and medications o Change to more appropriate diagnosis based on above with use of multiple secondary diagnosis to support o Write order to change diagnosis and document reason for change o Adjust medications covered

Comprehensive Assessment o Determined by the IDG o Related and unrelated diagnosis incorporated into plan of care o Should be an ongoing process when new diagnosis are added

Manifestation Code - Example 1 o Patient referred for vascular dementia – history of CVAs, hypertension, and peripheral vascular disease. Principal Diagnosis - Cerebral atherosclerosis or Late Effects of Cerebrovascular Disease Secondary Diagnosis – Vascular Dementia – Example given by Palmetto

Manifestation Code Mr. G is a 69yo BM on dialysis with ESRD. Renal failure is secondary to longstanding type I diabetes. What do you use as your principal diagnosis? A. Diabetes, secondary ESRD B. ESRD, secondary diabetes C. ESRD, no secondary diagnosis

Cause of Renal Failure? ICD-9 Guidelines o Diabetes – primary o ESRD – secondary ESRD is a manifestation of diabetes. ICD-9 codes states you need to list the etiology as principal diagnosis and follow the proper sequencing rules

Here’s the Confusion... o According to CMS claims manual, “the principal diagnosis is defined as the condition established after study to be chiefly responsible for the patient’s admission” o But the manual also says to follow ICD -9 coding guidelines. o Hospices generally list ESRD is the cause for the patients limited prognosis and use the LCD to support

What does CMS say? o Use ICD 9 guidelines o Hence in this case you would pay for the insulin/diabetes care and renal medications

What’s the Impact? o Medication and treatment costs likely to rise as more diagnosis are captured as secondary o Required to pay for all primary and secondary diagnosis

Proper Coding o HMD/staff physicians – understand basics – buy ICD manual o Do not use manifestation codes o Follow proper sequencing o Do not use mental codes o Do not use ill defined dx o Be as specific as you can in explaining diagnosis so coders can code accurately

Related VS Unrelated It is our general view that … “hospices are required to provide virtually all the care that is needed by terminally ill patients” (48 FR through 56011). Therefore, unless there is clear evidence that a condition is unrelated to the terminal illness, all services would be considered related. It is also the responsibility of the hospice physician to document why a patient’s medical need(s) would be unrelated to the terminal illness prognosis.

Related vs Unrelated Multiple interpretations as to the meaning of what are considered ‘‘related conditions” “Our expectation continues to be that hospices offer and provide comprehensive, virtually all-inclusive care.”

Related vs Unrelated o Chronic stable conditions o Pain unrelated to terminal diagnosis o Comorbidities requiring maintenance CMS states… “should be included in the bundle” “preexisting, chronic, or stable conditions – all interrelated”

Related Treatments o Unless clear evidence that a condition is unrelated to the terminal illness, all services would be considered related. o Physician needs to justify why a diagnosis is not being covered! o Must be documented!

Case Study Admissions team gets a referral on Mr. L for debility. (referral source uninformed) o NYHA III, EF = 25%, maximally treated o Atrial Fibrillation o COPD moderate-severe FEV1 = 35% o Alzheimer’s FAST 6 dementia o 10 pound wt loss BMI = 17, albumin 2.7 o Glaucoma o Admit under cardiac, COPD, or dementia? o What are your secondary diagnosis?

Physician Fills Out – IDG Process

Case Study Continued…. o Ms. L currently taking furosemide, metoprolol, digoxin, donepezil, memantine, tiotropium, fluticasone + salmeterol (advair), coumadin, and oxygen, eye drops Covered meds include: 1. Cardiac meds and oxygen 2. Cardiac, pulmonary meds, and oxygen 3. All meds except eye drops and oxygen

Determining Covered Medications o Principle: Heart failure – o Secondary: Atrial fib, hypertension, peripheral edema, depression o Cormorbids/Unrelated: hypothryoidism, diabetes, GERD, migraines Harder, PharmD, CGP, Julia. (2012). To Cover or Not To Cover: Guidelines for Covered Medications in Hospice Patients. The Clinician. 7(2), p1-3.

Question asked to CMS – 8/13 o Principle dx – COPD o Comorbidities - coronary artery disease and Parkinson's disease Doc stated unrelated to COPD and would only cover meds/tx for COPD CMS – this does not encompass holistic nature to exclude other conditions. Reiterated hospice should provide “virtually all the care.” Must be clear evidence as why it’s not related

CMS goes on to say….. o We have previously acknowledged that there are those rare circumstances in which a service may not be related to the patient's terminal prognosis and that this determination is to be done on a case-by-case basis by the hospice physician with input from the IDG.

Medication Costs Hospice Cost Report Data Are hospices paying for all necessary related medications? Why the decline? Is Part D taking the brunt of these payments? Where are your perdiem costs?

Here’s the Irony… o Rebasing of the nine components of the RHC o Drug costs = $3.74 in 2011 o Drug costs trending down o According to Abt Consultants (CMS) Anyone have drug costs at $3.74 ppd?

Part D Update

What about unrelated symptoms? Patient with NSCLC, end stage COPD, Class 3 heart disease, atrial fib, diabetes, peripheral neuropathy, spinal stenosis x 10 years. Patient has been on fentanyl 300 ug and gabapentin 2700 mg/d x 5 years. Do you cover?

Final Rule o Cover all symptom meds – acute or chronic o Used to be considered an inducement to pay for unrelated drugs o How are hospices handling this?

Department of Health and Human Services - Office of Inspector General o “Medicare Could Be Paying Twice for Prescription Drugs for Beneficiaries in Hospice” - June o Objective: To determine whether Medicare Part D paid for prescription drugs that likely should have been covered under the per diem payments made to hospice organizations.

Issue with Part D Medicare o Hospice beneficiaries had analgesics paid thru Part D – 334,387 prescriptions o 14.7% beneficiaries who had Part D o Cost was $13,000,430 o Fentanyl 39%, Oxycodone 18% Morphine 12%, Hydrocodone 9% Should hospices have paid for these? OIG – 2012 report – will be more audits

Review by ABT meds o 109,901,988 – hospice should cover 9,807,009 – analgesics 2,760,488 – antiemetics 937,521 – constipation meds 55,837,630 – meds related to debility 29,131,817 – meds related to FTT 1,558,089 – meds related to CHF Payment/Hospice/Downloads/May AnalysesToSupportPaymentReform.pdf

Average Payment Part D (per pt) o Idaho – $ o Average – $ o Texas – $ o Oregon - $79.93 o Connecticut - $58.78

Strategies to Combat Costs o Educate physicians on accurate coding diagnosis that relates to prognosis o Develop standardized forms to help with processes of coverage determination o Work with PBM to obtain lower costs o If not using – develop formulary o Consider pharmacist to review meds and make recommendations o Pay attention to response from MAC

Four Seasons Approach

Cost Effective Medications o Careful cost-effective choice of medications Ondansetron (Zofran) vs. Haloperidol (Haldol) Tiotropium (Spiriva) vs. Ipratropium (Atrovent) Methadone and LA morphine vs. OxyContin Citalopram(Celexa) vs. escitalopram (Lexapro) Esomeprazole (Nexium) vs. omeprazole (Prilosec) o Use generics when possible o Review costs via pharmacy benefits manager

Coding o Physician and coder need to work closely together

ICD 10 Codes o Oct 1, 2014 o Understanding crosswalking or mapping will be important to physicians during transition from ICD.9 to ICD.10 o Over new codes (14000 ICD.9) o GEMs – general equivalence mapping o Guide to crosswalking

ICD 10 o Full Implementation is expected by hospice organizations! o Specificity out to 7 numbers

Attending Physician - Risks o Hospice changes patient’s AOR when moved to an IPU for GIP, often to a NP o Hospice “assigns” a AOR o Hospice does not get signature of AOR on the initial certification At risks for survey deficiencies or non- compliance audits

AOR Changes o “Change in Attending” form required Includes physician’s full name Address and NPI number Effective date Date statement signed Patient/representative sig Acknowledgment choice of patient

Important Questions o Do you have a certified coder? o m_guidelines_2011.pdf m_guidelines_2011.pdf o Process for coding - Secondary Codes? o Diagnosis – “determined by physician” when/who decides? o Do you have an external audit?

ICD-10 Operational Perspective o Budget Resource Books Overtime Education o Staff will need to be trained o Physicians will need to be trained o Software, hardware, form revisions o Mapping of old and new codes Doctors: Start now!

Team Effort Across Departments o Collaboration necessary to identify systems impacted o Across clinical, financial and IS areas o Include HIM o IT – databases and necessary software o Administration support necessary

Attending of Record (AOR) o Patient chooses AOR o If changes, a patient files statement with new AOR with new date/signature o Risk Areas AOR changes when patient enters IPU Hospice choose the AOR AOR not signing certification

Notice of Election/Revocation o Both Notice of Election (NOE) and Notice of Termination/Revocation/ (NOTR) – submitted within 5 days o Risk Area Not having full proof process set up to capture. If late – no payment (similar to F2F)

Discussion o Great variation among hospices regarding related diagnosis and medications. How do you standardize this in your organization? o Need to develop processes to coordinate physician/admissions/coder

Questions that need clarification o Do you follow ICD-9 guidelines exclusively or the LCDs? Not mutually exclusive. o Diagnosis picked at admission o IDG/team physician - related determined at admissions and IDG o Ongoing diagnosis – falls under same process

Questions? Four Seasons Center of Excellence o HPC Solutions o Palliative Care Immersion Course o Mentoring – physicians, nurse practitioners and physician assistants