08/23/2017
You Asked....We Answered
This week's You Asked..We Answered question asks "Are both the Certification of Terminal Illness (CTI) and Plan of Care (POC) to be completed prior to billing? My understanding was that we need the signed CTI returned before we release the bill, and as long as the hospice POC has been sent, we can release the bill… is this correct? Furthermore, will we ever need to make sure the Hospice POC is signed and returned for billing purposes? Or is it solely for the purpose of physician orders?”
You Asked:
"Are both the Certification of Terminal Illness (CTI) and Plan of Care (POC) to be completed prior to billing? My understanding was that we need the signed CTI returned before we release the bill, and as long as the hospice POC has been sent, we can release the bill… is this correct? Furthermore, will we ever need to make sure the Hospice POC is signed and returned for billing purposes? Or is it solely for the purpose of physician orders?"
We Answered:
The ONLY document you need to have signed by the physicians before you can bill is the CTI. You need to get signatures for all physician orders including the POC but not before you bill your claims.
Please see the two citations below from the (COP’s) that refer to the CTI being signed by the physician and on file in the patient’s record before a claim is billed.
Also below is a citation regarding the POC; the POC does NOT have to be signed by the physician. In practice, many hospices use the POC as the initial orders for the hospice patient, in which case, it would need to be signed by a physician. However, according to the COP’s, a hospice only has to show physician involvement in the POC, and not necessarily a signature.
Hospice Medicare Manual Chapter 9:Certification and Election Requirements
(Rev. 1, 10-01-03) A3-3141, HO-204
20.1 - Timing and Content of Certification
(Rev. 188, Issued: 05-01-14; Effective: 08-04-14; Implementation: 08-04-14)
For the first 90-day period of hospice coverage, the hospice must obtain, no later than 2 calendar days after hospice care is initiated, (that is, by the end of the third day), oral or written certification of the terminal illness by the medical director of the hospice or the physician member of the hospice IDG, and the individual’s attending physician if the individual has an attending physician.
The attending physician is a doctor of medicine or osteopathy who is legally authorized to practice medicine or surgery by the state in which he or she performs that function, or a nurse practitioner, and is identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individual’s medical care. A nurse practitioner is defined as a registered nurse who performs such services as legally authorized to perform (in the state in which the services are performed) in accordance with State law (or State regulatory mechanism provided by State law) and who meets training, education, and experience requirements described in 42 CFR 410.75.
Note that a rural health clinic or federally qualified healthcare clinic (FQHC) physician can be the patient’s attending physician but may only bill for services as a physician under regular Part B rules. These services would not be considered rural health clinic or FQHC services or claims (e.g., the physicians do not bill under the rural health clinic provider number but they bill under their own provider number).
Initial certifications may be completed up to 15 days before hospice care is elected. Payment normally begins with the effective date of election, which is the same as the admission date. If the physician forgets to date the certification, a notarized statement or some other acceptable documentation can be obtained to verify when the certification was obtained.
For the subsequent periods, recertifications may be completed up to 15 days before the next benefit period begins. For subsequent periods, the hospice must obtain, no later than 2 calendar days after the first day of each period, a written certification statement from the medical director of the hospice or the physician member of the hospice’s IDG. If the hospice cannot obtain written certification within 2 calendar days, it must obtain oral certification within 2 calendar days. When making an oral certification, the certifying physician(s) should state that the patient is terminally ill, with a prognosis of 6 months or less. Because oral certifications are an interim step sometimes needed while all the necessary documentation for the written certification is gathered, it is not necessary for the physician to sign the oral certification. Hospice staff must make an appropriate entry in the patient's medical record as soon as they receive an oral certification.
The hospice must obtain written certification of terminal illness for each benefit period, even if a single election continues in effect.
A written certification must be on file in the hospice patient’s record prior to submission of a claim to the A/B MAC (HHH). Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. Initially, the clinical information may be provided verbally, and must be documented in the medical record and included as part of the hospice's eligibility assessment.
[…]
418.56(c) Standard: Content of the plan of care
The hospice must develop an individualized written plan of care for each patient. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following:
Procedures and Probes §418.56(c)
- Determine through interview/observation and record review if the plan of care identifies all the services needed to address problems identified in the initial, comprehensive and updated assessments.
- Is there evidence of patients receiving the medication/treatments ordered?
- Are plans of care individualized and patient-specific?
- Does the plan of care integrate changes based on assessment findings?
- Is there documentation to support that the development of the plan of care was a collaborative effort involving all memebers of the IDG and the attending physician, if any? THe attending physician and the IDG members do not have to sign the plan of care but there must be documentation of their involvement.
If you have a question you would like to see featured in You Asked..We Answered, email Nisha Hammel, Director of Advocacy at nhammel@leadingageohio.org , or Anne Shelley, Director of Professional Development & HH/Hospice Regulatory Relations, at ashelley@leadingageohio.org.
