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| July 27, 2021 |
Home Health and Hospice NewsletterIn Today's Newsletter
Deadline to register for LeadingAge Ohio 2021 Annual Conference and Trade Show: Friday, July 30Join us August 4-6, 2021 at the Hilton Columbus at Easton for the LeadingAge Ohio Annual Conference and Trade Show. This year’s theme is FORWARD! With the LeadingAge Ohio Annual Conference & Trade Show less than two weeks away, don’t wait – register today! The deadline to register is Friday, July 30. If you are unable to register by July 30, you must register on site. Take advantage of fifty-five excellent breakout sessions, continuing education credits, inspiring keynote speakers, networking opportunities, and much, much more at the can’t-miss in-person event of the summer for our members and partners! To register for the LeadingAge Ohio Annual Conference & Trade Show, please click here. You asked... We answered regarding hospice continuous home care criteria
You Asked: May a hospice use Continuous Home Care (CHC) in instances where the family wants to care for their loved one, but feels intimidated and uncertain how to care for them? May we use CHC to teach them, stabilize the environment, assess learning, and reinforce procedures in order to prevent a crisis when they don’t know what to do in a situation? We Answered: According to the conditions of participation, the situation you described could constitute a Continuous Home Care (CHC) day as long as you are teaching the family how to prevent a crisis. Be sure your team is documenting what they are doing to prevent the crisis and to keep the patient in their place of residence. It would seem in these cases the nurse would need to be the one teaching the family and attempting to prevent the crisis. I am not sure this type of CHC would be appropriate for a hospice aide to make up many of the CHC hours. Please see the citation below from the Hospice Medicare Benefit Manual Chapter 9, in particular, the areas I highlighted in yellow. If you have questions about CHC or any level of hospice care, please contact Anne Shelley at ashelley@leadingageohio.org. 40.2.1 - Continuous Home Care (CHC) Continuous home care may be provided only during a period of crisis as necessary to maintain an individual at home. A period of crisis is a period in which a patient requires continuous care which is predominantly nursing care to achieve palliation or management of acute medical symptoms. If a patient’s caregiver has been providing a skilled level of care for the patient and the caregiver is unwilling or unable to continue providing care, this may precipitate a period of crisis because the skills of a nurse may be needed to replace the services that had been provided by the caregiver. This type of care can also be given when a patient resides in a long term care facility. However, Medicare regulations do not permit CHC to be provided in an inpatient facility (a hospice inpatient unit, a hospital, or SNF). The hospice must provide a minimum of 8 hours of nursing, hospice aide, and/or homemaker care during a 24-hour day, which begins and ends at midnight. This care need not be continuous, e.g., 4 hours could be provided in the morning and another 4 hours in the evening. In addition to the 8 hour minimum, the services provided must be predominantly nursing care, provided by either an RN, an LPN, or an LVN. Services provided by a nurse practitioner that, in the absence of a nurse practitioner, would be performed by an RN, LPN, or LVN, are nursing services and are paid at the same continuous home care rate. This means that more than half of the hours of care are provided by an RN, LPN, or LVN. Homemaker or hospice aide services may be provided to supplement the nursing care. NOTE: When fewer than 8 hours of care are required, the services are covered as routine home care rather than continuous home care. Nursing care in the hospice setting can include skilled observation and monitoring when necessary, and skilled care needed to control pain and other symptoms. The development of the CHC rate included the daily costs of nursing, hospice aide, social worker, and therapy visits; drugs; supplies and equipment; and the average daily cost of the hospice IDG. However, the statute limits the billable CHC hours of direct patient care to care provided by a nurse, a homemaker, or a hospice aide. Medicare regulations require that an hourly payment be made. While in the majority of situations, one individual would provide continuous care during any given hour, there may be circumstances where the patient’s needs require direct interventions by more than one covered discipline resulting in an overlapping of hours between the nurse and hospice aide. In these circumstances, the overlapping hours would be counted separately. The total hours paid cannot exceed 24 hours per day. The hospice would need to ensure that these direct patient care services are clearly documented and are reasonable and necessary. Computation of hours of care should also reflect the total hours of direct care provided to an individual that support the care that is needed and required. This means that all nursing and aide hours should be included in the computation for CHC and when the aide hours exceed the nursing hours, CHC would be denied and routine payment will be made. The statutory definition of continuous home care is meant to include the full range of services needed to achieve palliation and management of acute medical situations. Deconstructing what is provided in order to meet payment rules is not allowed. In other words, hospices cannot discount any portion of the hours provided in order to qualify for a continuous home care day. Documentation of care, modification of the plan of care, and supervision of aides or homemakers would not qualify as direct care nor would these activities qualify as necessitating the services of more than one care provider. In addition, while the services provided by other disciplines such as medical social workers or pastoral counselors are an integral part of the care provided to a hospice patient, these services are not included in the statutory definition of continuous care and are not counted towards total hours of continuous care. However, the services of social workers and pastoral counselors would be expected during these periods of crisis, if warranted as part of hospice care, and are included in the provisions of routine hospice care. The following are used to illustrate circumstances that may qualify as CHC. This list is not all-inclusive nor does it indicate that if a patient presents with similar situations, that it would constitute CHC. Frequent medication adjustment to control symptoms/collapse of family support system Situation A: The patient has had a central venous catheter inserted to provide access for continuous Fentanyl drip for pain control and for the administration of antiemetic medication to control continuous nausea and vomiting. The nurse spends 2 hours teaching the family members how to administer IV medications. She returns in the evening for 1 hour. The hospice aide provides 3 hours of care. The nurse spends 2 hours phoning physicians, ordering medications, documenting and revising the plan of care. Situation B: The patient experiences new onset seizures. He continues to have episodes of vomiting. The nurse remains with the patient for 4 hours (10 AM – 2 PM) until the seizures cease. During that time she provides skilled care and family teaching. The patient’s wife states she is unable to provide any more care for her husband. A hospice aide is assigned to the patient for monitoring for 24 hours, beginning at 2:00 PM, with a total of 8 hours of direct care in the first day. The nurse returns intermittently for a total of an additional 5 hours to administer medications, assess the patient and to relieve the aide for breaks. The social worker provides 3 hours of services to work with the patient’s wife in identifying alternative methods to care for the patient. Symptom management/rapid deterioration/imminent death Situation A: 77-year-old patient with lung cancer whose caregiver is 80 years old. The caregiver has been caring for this patient for 4 months and is now exhausted and scared. The care provided consists of assisting with bathing, assisting the patient to ambulate, preparing meals, housekeeping and administering oral medications. Since the patient is dyspneic at rest, she requires assistance in all ADLs, which equates to 9 hours of assistance within a 24-hour period. Determination: This would not qualify as CHC since there is little nursing care that requires a nurse. The patient would however be a candidate for an inpatient respite level of care. Situation B: The patient’s condition deteriorates. The patient now has circumoral cyanosis, respiratory rate of 44 and labored with intermittent episodes of apnea. The nurse performs a complete assessment and teaches the caregiver on methods to make the patient comfortable. The nurse returns twice within the 24 - hour period to assess the patient. She revises the plan of care after conferring with the patient’s attending physician and with the hospice physician. The homemaker and hospice aide are sent to assist the caregiver. Within the 24-hour period, the direct care provided by the nurse equates to 3 hours, homemaker with 2 hours, and hospice aide of 6 hours. Determination: Since only 3 of the 11 hours were skilled care requiring the services of a nurse, this would not constitute CHC. In this situation, the care required is not predominantly nursing but are comprised of services provided by a hospice aide. In addition, it would not be correct to discount any portion of the hospice aide’s hours or to provide these services gratis in order to qualify for the CHC benefit. Situation C: The next day, the patient’s condition deteriorates further. She has increased periods of apnea and air hunger. In addition she is experiencing continuous vomiting and increasing pain. Her blood pressure is beginning to decrease and her respirations are increasing. The nurse remains at the patient’s bedside for 4 hours while attempting to control her pain and symptoms. The hospice aide provides care during 1 hour of this period. The nurse leaves and the hospice aide remains at the bedside for 3 hours. The social worker comes and talks with the caregiver and remains for 1 hour. The nurse returns while the aide leaves. The nurse remains with the patient for 2 hours until she dies. The social worker returns and stays with the caregiver for 1 hour until the mortuary arrives. Determination: The nurse provided 6 hours of direct skilled nursing care; the aide provided 4 hours of direct care resulting in a total of 10 hours of registered nurse and hospice aide care. Since at least 6 of the 10 hours were direct nursing care, and since nursing care was the predominant service provided during the 10 hours, the care meets the criteria for CHC. In addition, since the nurse and the aide provided direct care for the patient simultaneously, it would be appropriate to bill for each resulting in total of 10 billable hours. The patient received 12 hours of care. The 2 hours for the social worker are not counted towards the CHC hours. Medicare’s requirements for coverage of CHC are that at least 8 hours of predominantly nursing care are needed in order to manage an acute medical crisis as necessary to maintain the individual at home. When a hospice determines that a beneficiary meets the requirements for CHC, appropriate documentation must be available to support the requirement that the services provided were reasonable and necessary and were in compliance with an established plan of care in order to meet a particular crisis situation. This would include the appropriate documentation of the situation and the need for continuous care services consistent with the plan of care. Continuous home care is only furnished during brief periods of crisis and covered only as necessary to maintain the terminally ill individual at home. LeadingAge home health and hospice recapEach week, LeadingAge provides a recap regarding home health and hospice. This week's edition featured upcoming home health and hospice member meetings and discussions with CMMI on future care delivery models. Read the complete recap here. CMS updates ABN chapter of the Medicare Claims Processing ManualThe Centers for Medicare & Medicaid Services (CMS) recently revised the Advance Beneficiary Notice of Non-coverage (ABN) section 50 in chapter 30 of Pub. 100-04, Medicare Claims Processing Manual via Transmittal l 10862/Change Request (CR) 12242. The changes are primarily a reorganization of the material, clarifications, and updates. For instance, some of the examples used have been updated, some deleted, and CMS addresses some common issues more directly and clearly. The section pertaining to hospices, 50.17 D, no longer contains the examples of when an ABN is mandatory for hospice beneficiaries. The examples that were previously included are still applicable and copied below for member convenience. Hospice: Medicare Claims Processing Manual, Chapter 30, Rev. 4250, 03-08-19: Below are examples of scenarios that mandate ABN issuance and the accompanying denial reason that could be listed in Blank (E) on the ABN.
Reason in Blank “E” on the ABN: “Medicare does not pay for hospice care when your illness is not considered terminal.”
Reason in Blank “E” on the ABN: “Medicare will not pay for this level of care when it is not medically reasonable and necessary.”
Reason in Blank “E” on the ABN: “Medicare will not pay for physician visits that are not medically reasonable and necessary.” The section pertaining to home health agencies, 50.17 F, also has an example removed. However, it may be helpful to agencies to have this information and it is copied below for member convenience. Home Health: Medicare Claims Processing Manual, Chapter 30, Rev. 4250, 03-08-19: An ABN is required at initiation only when there is potential for the beneficiary or his/her secondary insurance to incur a charge. The ABN informs the beneficiary of the potential charges and allows him/her to make a decision regarding whether or not s/he wants care that won’t be paid for by Medicare. An ABN signed at initiation of home health care for items and/or services not covered by Medicare is effective for up to a year, as long as the items/services being given remain unchanged from those listed on the notice.
The ABN must be issued to this beneficiary before providing home care that will not be paid for by Medicare. This allows the beneficiary to make an informed decision on whether or not to receive the non-covered care and accept the financial obligation. Any one-time care that is provided and completed in a single encounter is considered an initiation in terms of triggering events and is subject to ABN issuance requirements if applicable. Other instructional components that were previously included in only the home health or hospice section of the Manual but are applicable to additional provider types were moved and are now covered in new sections. This restructuring of the Manual should provide more clarity to providers. Current ABN forms can be found here. CMS issues system changes for the home health NOAThe Centers for Medicare & Medicaid Services’ (CMS) Change Request 12227 outlines the business requirements describing the changes to the Medicare systems to implement processing of the notice of admission (NOA) and claims. NOAs will be submitted using type of bill (TOB) 32A and may be cancelled using TOB 032D. All claims for periods of care following the admission will be submitted using TOB 329. The National Uniform Billing Committee has redefined TOB 329 to represent an original claim, rather than an adjustment, for all claims with From dates on or after January 1, 2022. This redefinition allows HHAs to continues use the TOB 329 even with the elimination of the request for anticipated payment (RAP). As with the no-pay RAP, the NOA submission criteria will require HHAs having a verbal or written order from the physician that contains the services required for the initial visit, and that the HHA has conducted an initial visit at the start of care. There will be a non-timely submission reduction in payment amount tied to any late submission of NOAs when the HHA does not submit the NOA within 5 calendar days from the start of care. That is, if an HHA failed to submit a timely NOA, the reduction in payment amount would be equal to a 1⁄30th reduction to the wage-adjusted 30-day period payment amount for each day from the home health start of care date until the date the HHA submitted the NOA. Among the business requirements listed in the CR, section 12227.1.4 includes the following required data elements for NOA: Type of Bill 032A or 032D
CMS plans to issue a separate Change Request to update the Medicare Claims Processing Manual to describe the changes to providers and provide detailing NOA submission instructions and revised billing instructions. August 4 Hospice Quality Reporting Program forumOn Wednesday, August 4, the Centers for Medicare & Medicaid Services (CMS) will host a webinar to share updates on the on the fiscal year (FY) 2022 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements Final Rule. During this webinar, a CMS subject matter expert will provide information on the following topics:
CMS will answer questions at the end of the webinar, as time permits. Webinar Details: To register, please click here. Participation Information After you register, you will receive a dial-in number and webinar link. You will not be able to share your registration information as it will be unique to you. Please check your spam filter if you do not receive an email confirmation. Attendees will be able to submit questions in various ways, including:
For more information, please email CMSQualityTeam@ketchum.com. Public Health Emergency renewed; Waivers extendedAs expected, the Department of Health and Human Services (HHS) Secretary Becerra renewed the national COVID-19 Public Health Emergency yesterday. The renewal is good for 90 days and is available to review here. With this extension, the 1135 federal blanket waivers issued by the Centers for Medicare & Medicaid Services (CMS), which include nurse aide training waivers and waiver of the 3-day hospital stay requirement, are also extended. Many members have reached out to LeadingAge Ohio because their hospital partners have been concerned about the termination of the 3-day stay waiver. The Centers for Medicare & Medicaid Services (CMS) has not announced termination of the 3-day stay waiver. With this week’s extension of the national public health emergency due to COVID-19, the 3-day stay waiver and all other 1135 federal blanket waivers remain in effect unless otherwise noted by CMS. Earlier this year, in a letter to Governors, Secretary Becerra made it clear that the PHE would likely be extended through the remainder of 2021. CMS is continuously monitoring the waivers and may make changes based on what they feel the necessity of these waivers may be, including ending some waivers prior to the end of the PHE. LeadingAge Ohio will share updates should CMS make any changes. Ohio files ‘Plan to Plan’ for extra home- and community-based Medicaid services fundingOhio has not yet defined the services it plans to fund via new funding included in the federal American Rescue Plan (ARP) set aside for home- and community-based services (HCBS), but recently filed a plan that spells out how it will engage stakeholders to determine the best uses for the money. Maureen Corcoran, director of the Ohio Department of Medicaid (ODM), told Hannah News the submission filed with the federal Centers for Medicare and Medicaid Services (CMS) last week is “a plan to plan,” given that ODM was focused heavily on state budget deliberations until recently. Corcoran said the extra $460 million in HCBS that Ohio can earn from the federal government through March 2022 has many more conditions placed on its use than the general purpose enhanced FMAP funding Ohio has received during the pandemic. She likened it to the federal “Money Follows the Person” program for encouraging greater use of HCBS. The funding can be used to draw down additional federal money under the usual matching arrangement for Medicaid if used on eligible services. The money must be spent by March 2024. Corcoran said uses for the funding under consideration now include relief payments to providers to address stresses of the pandemic, improvements to system infrastructure and workforce development strategies -- a major concern. More details on uses for the funding will emerge in quarterly reports ODM will have to file with CMS on the funding, Corcoran said. “In order to maximize the impact on the delivery system, the first step must be an intentional and inclusive planning process. The Ohio Department of Medicaid, in conjunction with our partner agencies --ODA, DODD, OhioMHAS and ODE -- are committed to a transparent planning process that considers perspectives of the individuals we serve, our providers and our advocates. Initial work to identify opportunities for strategic investment that are impactful and sustainable is underway. As we continue our planning process, we anticipate new ideas and more defined priorities. A focused strategic plan will be detailed in upcoming quarterly updates to Ohio’s HCBS Spending Plan,” the plan states. To review Ohio’s plan, click here. To review a letter that LeadingAge Ohio provided to the Department of Medicaid on both eFMAP funding and American Recovery Plan (ARPA) funding, click here. (Ohio Capitol Connection) What the Media Said about end of life care this week – July 27, 2021
Throughout the pandemic, hospice and end-of-life care has been discussed across the country. LeadingAge Ohio reviews articles and media each week to share with our members. Upcoming Educational OpportunitiesHospiLearn Webinars for August - November
HospiLearn Webinars: Earn continuing education credits through online educational programs.
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