Components Of FY2014 Proposed Hospice
Wage Index Rule – Posted April 29, 2013
Hospice Wage Index And Payment Rate Update
Hospice Quality Reporting Requirements
Updates On Payment Reform

2
FY2014 Hospice Wage Index
Proposed Rule

Proposed FY2014 Hospice Payment Update Percentage
Hospital Marketbasket 2.5%
Productivity adjustment reduction

Hospice-specific marketbasket reduction
FY2014 Hospice Payment Update %
-0.4%
-0.3%
1.8%
- 0.7%

Updated wage index
Estimated Final FY2014 Hospice Payment
Update %
1.1%


FY2014 wage index tables
 http://www.cms.gov/Medicare/Medicare-Fee-for-
Service-Payment/Hospice/index.html

NHPCO will issue wage index calculator and stateby-state charts in coming days

Watch NHPCO website at www.nhpco.org/regulatory

4
Level of Care FY2013
National Rate
Routine Home
Care
Continuous Home
Care
Inpatient Respite
General
Inpatient Care
$153.45
$895.56
$158.72
$682.59
FY2014
National
Rate
$156.21
FY2014
National Rate with
Sequestration
$153.08
$911.68
$161.58
$694.88
$893.45
$158.35
$680.98

5

Coding requirements – NO debility or adult failure to thrive

Implementation of HIS – Hospice Item Set for all patients

Implementation of Hospice Experience of Care survey (Hospice CAHPS)

Payment Reform

Cost report changes

7
Debility, Adult Failure to Thrive
Alzheimer’s and Other Dementias
Using ICD-9-CM Coding Conventions

Clarifications on Coding Requirements
8

“All of a patient’s coexisting or additional diagnoses” related to the terminal illness or related conditions should be reported on the hospice claims

72% of hospice claims report only one diagnosis

CMS conclusions.....

9





Diagnoses found in “Symptoms, Signs, and Ill-
Defined Conditions” section of ICD-9-CM
“Debility” and “adult failure to thrive” SHOULD
NOT be used as principal hospice diagnoses on the hospice claim form
Reference – ICD-9-CM Coding Manual
Choose the diagnosis “most contributory” to the terminal illness
Claims with this diagnosis will not be paid and will be returned to provider (RTP)

10

Diagnoses in coding classification “Mental,
Behavioral, and Neurodevelopmental Disorders”

Not allowable as a principal diagnosis per ICD-9-CM coding guidelines

Diagnoses in ICD-9-CM coding classification
“Diseases of the Nervous System and Sense
Organs”

Can be used as principal diagnoses per ICD-9-CM coding guidelines

Final Message on Coding Conventions
11



Imperative that hospice providers follow ICD-9-CM coding guidelines and sequencing rules for all diagnoses
Pay particular attention to dementia coding

Dementia codes found in more than one ICD-9-CM coding chapter
Code the most definitive, contributory terminal illness in the principal diagnosis field
 with all other related conditions in the additional diagnoses fields for hospice claims reporting

13

14

2013/2014 Data Collection and Submission

QAPI structural measure

NQF #0209 – pain measures

CMS proposes that these measures discontinued after FY2014 data collection year OR

CMS proposes to continue using #0209 until another pain outcome measure is available

15

Hospice Item Set (HIS)

Proposed to implement July 1, 2014

Data on admission and discharge of every patient

Data collection to include information for 7 new quality measures

Hospices who fail to report quality data via the HIS system in 2014 will have a 2% marketbasket reduction for FY2016

Public reporting on hospice quality measures

Not initiated prior to 2017

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NQF Measure #
NQF #1617
NQF #1634
NQF #1637
NQF #1638
NQF #1639
NQF #1641
NQF #1647
Hospice Quality Measure Description
Patients Treated with an Opioid who are Given a Bowel Regimen
Pain Screening
Pain Assessment
Dyspnea Treatment
Dyspnea Screening
Treatment Preferences
Beliefs/Values Addressed (if desired by the patient)

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 http://www.cms.gov/Regulations-and-
Guidance/Legislation/PaperworkReductionActof19
95/PRA-Listing-
Items/CMS1252151.html?DLPage=1&DLSort=1&D
LSortDir=descending

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
One form for each admission


Administrative information
Measure support information

Preferences
 NQF #1641 – Treatment preferences
 NQF #1647 – Beliefs/Values Addressed (if desired by the patient)


Health conditions



NQF #1634 Pain Screening
NQF #1637 Pain Assessment
NQF #1638 Dyspnea Treatment
 NQF #1639 Dyspnea Screening
Medications
 NQF #1617 - Patients treated with an opioid who are given a bowel regimen

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
One form for each discharge

Demographic data

Reason for discharge

20

Hospice Experience of Care Survey

Post-death caregiver survey

Hospices required to contract with a vendor for survey administration and quarterly data submission

Proposed start date: CY2015

First quarter – “dry run” for at least 1 month

Mandatory compliance – April 1, 2015

Fewer than 50 deaths in year: exempt

21
 http://www.cms.gov/Regulations-and-
Guidance/Legislation/PaperworkReductionActof19
95/PRA-Listing-Items/CMS-
10475.html?DLPage=1&DLFilter=hospice&DLSort=
1&DLSortDir=descending

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
Home

Nursing Home

Inpatient o o
Set of core questions with additional setting specific questions
Location at death determines which version is used

Reconsideration process for hospice quality reporting

A process will be created to allow hospices that have been notified of non-compliance with hospice quality reporting requirements

May request reconsideration of FY 2014 payment determinations


U-shaped model of resource use

Considering a tiered approach with payment tiers based on length of stay

Short-stay add-on payment

Case-mix adjustment

Rebase ( ) the routine home care rate

Site of service adjustment for hospice patients in nursing facilities

27

Higher payments at the beginning of care

Higher payments in the last days of life

Lower payments in the “middle” of care

No determination on number of days or payment level

28

Could improve payment accuracy

Somewhat like home health Low Utilization
Payment Amount (LUPA)

29

Could be considered when more diagnosis data is available

Contingent on data gathering from multiple diagnoses on claim form

Rebase the Routine Home Care Rate
Routine Home
Care Components
1983 Cost per
Day
Inflation Factor
FY2011 Cost per Day
Nursing Care
Home Health Aide
Social
Services/Therapy
Home respite
Interdisciplinary group
Drugs
Supplies
Equipment
Outpatient
Hospital Therapies
TOTAL
$16.25
$12.74
$3.23
$1.46
$2.78
$2.78
$4.49
$1.13
$2.99
$46.25
N/A
N/A
N/A
X 3.1704
X 3.1704
X 3.1704
X 3.1704
X 3.1704
X 3.1704
Note: No action proposed on this issue this year.
$56.54
$19.24
$10.29
$4.63
$8.81
$3.74
$14.23
$3.58
$9.48
$130.54
Example of rates for
FY2014
$60.83
$20.70
$11.07
Proposed
FY2014
Rates
$4.98
$9.48
$4.02
$15.31
$3.85
$10.20
$140.44
$156.21

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





Do not have the data to support rebasing six of the nine cost components described in the 1983 final rule
Drugs, supplies, and equipment costs -- not available from hospice claims data
Cost report data not sufficiently detailed
Could consider rebasing:



Nursing
Home health aide
Social services/therapy
Comprise 69.7% of RHC rate
Use FY2011 cost report data matched to FY2011 claims data

Site of service rate adjustment for nursing home patients on hospice

Issues

Growth
 OIG Report in 2011 – 263 hospices have 66% or more patients in nursing homes

Possible efficiencies – multiple patients in one nursing home, < drive time and < mileage

Higher aide visits and time for hospice patients in nursing homes

NO action proposed on this issue this year


January 2013, CMS received comments regarding additional data collection

Considering input

Additional data to be issued as a change request
(CR) this spring or summer


MedPAC – U-shaped curve and modeling

June 2013 Report to Congress

CMS

Abt Associates and Technical Expert Panel

Extensive analysis of claims and cost report data

HHS Assistant Secretary for Planning and Evaluation

ASPE

Extensive data analysis – especially visits and visit length

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ALUE
ASED
URCHASING

Value based purchasing – pilot testing


Utilize already implemented measures
Implement pilot by January 1, 2016


Go to www.regulations.gov

In the search box, type hospice

The proposed rule, CMS-1449-P, will come up.
Click the blue “Comment Now” box to submit your comments.

An official letter from your hospice may be attached.


Address the letter as follows:
Marilyn Tavenner, Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS–1449–P
P.O. Box 8010
Baltimore, MD 21244–8010

Comments are due June 28, 2013

Thank you for your time and input!