Final Rule in Regulatory Challenges—How are You Affected?

Larry Beresford

A dense, 49-page government document with a mouthful of a title, “Medicare Program; FY 2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements; and Updates on Payment Reform” was published in the Federal Register on August 7—with huge implications for hospices and their medical directors.

This Final Rule does much more than update the annual Hospice Wage Index. It also covers changes in hospice quality reporting, looming reform of the hospice payment system, and a range of other regulatory issues. Appropriate eligibility for hospice care remains a major focus for the government. But hospices face new requirements in spelling out the primary diagnosis for this eligibility, all related comorbidities and secondary conditions, what is related or unrelated to the terminal prognosis, and how all of the above should be coded on claims forms, described in physician narrative statements and certified by two physicians in their best medical judgment. Some terminal prognoses, notably adult failure to thrive and debility unspecified, will no longer be permitted as primary diagnoses for hospice admissions.

All of this means the role and responsibilities of hospice medical directors are growing. Read much more about the regulatory challenges they now face in the Quarterly. You can also see how AAHPM’s comments on the proposed rule compare to the final regulations in this side-by-side prepared by the Academy’s lobbying and consulting firm, Hart Health Strategies.

1 thought on “Final Rule in Regulatory Challenges—How are You Affected?

  1. I think the section regarding ICD coding should be required reading in particular. It provides some great guidelines that should influence physician narratives in hospice.

    I think it might be very interesting for AAHPM to provide some guidance on appropriate coding and this will be especially true after 9/30/2014 when ICD 10 is required.

    Wouldn’t it make more sense to code the principle diagnosis as specifically as possible? For example in the document it lists 496 as the COPD code used, but if I were coding a patient with COPD in the office I would usually try and use 491.20 or 491.21 which are 5 digit codes. Likewise for CVA it lists 436 which is appropriate for acute CVA, but many of our patients are late CVA and in those cases wouldn’t we be better with some variation of 438.xx?

    Also, there are several comments in the ICD section about hospices having to “hire professional coders,” but I would argue that hospices should begin asking their physicians to have greater input on this area. For example, for each newly admitted patient have the hospice medical director provide a simple list of principle and supporting diagnosis that THE hospice is addressing. I think this is important as once the patient is on hospice the treatment priority changes quite a bit. To clarify this, I’d use the example of the patient who had Alzheimer’s and clearly that would be the hospice admitting diagnosis. However, prior to coming on service the hospitalizations dealt with repeated aspiration pneumonia with x.x bacteria. However, now the focus is on comfort care and managing the dysphagia as best the hospice can, so NOW list dysphagia v repeatedly listing aspiration pneumonia unless the patient clearly has ongoing pneumonia.

    Maybe I could shorten this entire post and say I would hope that hospice diagnosis coding ought to reflect the care the hospice is providing and I “think” that most hospices are taking their ongoing coding from some admission H and P only. If I am totally wrong on that one then “oops.”

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