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Certification of Terminal Illness For Hospice Care in the United States Video Transcription

Hello! My name is Sara Graham. I will be reviewing certification of terminal illness for hospice care in the United States. There are three videos on this website that you should watch prior to continuing with this one. The first is Hospice Care in the United States, which is a great overview of the hospice benefit. The second, and in my opinion, most important, is Prognostication, by Jillian Gustin. Without it, you won’t understand the data I will be presenting here. The third is Consultation Etiquette, which helps us strengthen our case for patients that may be borderline at admission.

Our goals are not only to make sure you feel comfortable with understanding what certification is, but also to help you complete them efficiently and effectively. I will review the certification process, and take a look at how local coverage determination criteria informs the format we recommend. I also have a number of case examples highlighting some difficult situations to share with you.

First, let’s describe the five W’s guiding this process. Why we do this? It is because it is a federal regulation required of us by Medicare. Who can complete them? It has to be a Hospice Medical Director or a hospice physician. No one else. What is it? It is a signed document stating the patient qualifies for hospice, and that they more than likely will die in the next six months. When does a certification occur? Any time from two days prior to fifteen days after enrollment. And where does this occur? On paper.

You do not need to see a patient in order to complete the initial certification. But you must understand the patient’s situation thoroughly. This understanding comes from practicing consultation etiquette, talking with a referring physician, and speaking with the admitting hospice nurse directly. If you have concerns about the patient qualifying for hospice, evaluate the patient face-to-face to inform your medical opinion.

There are three key concepts to consider when performing the initial certification of a patient for hospice care. Patient prognosis, your own medical opinion, and as usual in our business, the fact we can only give a prospective look.

We use the components of population data, performance status, and disease-specific prognostic indicators to determine prognosis, or our belief that the patient has six months or less to live. We have a statement we recommend you include in each certification. We will build on this statement in the next few slides.

To be eligible for hospice care, you must be able to write, “I believe that patient X has a prognosis of less than six months.” The next component of certification uses our clinical sixth sense on whether they qualify or not. Our sixth sense is just as important as the objective data supporting your prognosis.

This is where the “in my medical opinion” statement is added on. The statement now becomes, “In my medical opinion, I believe the patient has a prognosis of less than six months.”

If you aren’t sure about prognosis, if your clinical sixth sense is uncertain, you can use the surprise question, “Would I be surprised if during the next six months my patient was to die?” If the answer is “no, you wouldn’t,” they likely qualify for the hospice level of care.

The other question to ask yourself is how hospice may be able to add value to the patient care. For example, does it allow them to remain at home? Are their symptoms better controlled? This information is more important during recertification because it clearly proves the need of continued hospice services.

One of the most important things to remember about our medical opinion and our expected prognosis, is that this is a prospective opinion. We do not have the luxury of retrospection like reviewers. So, if there is a 51% probability of death, we need to be okay with being wrong 49% of the time.

Some people will surprise us. Some people live longer than expected prognosis. That is wonderful for that patient. The statement now becomes, “In my medical opinion, I believe the patient has a prognosis of less than six months if the illness runs its normal course.” But if a patient does live longer, what does this mean? Do we sign them off of hospice care? Are we penalized for being wrong? I will tell you that previously, hospices would be audited, and were forced to return payments. This was dependent on a percentage of patients living beyond the expected prognosis.

This all changed with a letter penned by Nancy DeParle. A lawsuit was brought against Medicare due to the financial penalties some hospice companies were forced to repay. Out of it, sprung this. And this is what she wrote: “Let me be clear. In no way are hospice beneficiaries restricted to six months of coverage. There is no limit on how long an individual beneficiary can receive hospice services, as long as they continue to meet the eligibility criteria.”

Also, “As long as a physician continues to properly and conscientiously recertify the six month prognosis, a beneficiary can continue to receive the hospice benefit.” This simple letter gave many physicians the confidence to refer patients to hospice sooner.

Process To Certify Terminal Illness

Let’s next briefly look at an overview of the certification process.

Here you can see the timing of each component of certification and recertification. When the initial certification of terminal illness is completed, the patient is then admitted to hospice care for 90 days. Many people think when on hospice, you stay on. And that is not the case.

When writing an initial certification note, it’s important to understand the nomenclature we use. Primary hospice diagnosis is just that, the main reason we are admitting them to hospice.

Secondary conditions relate to the hospice diagnosis, like spinal cord compression from cancer. We add these to paint the picture of the patient, and strengthen the certification. Many of them are disease-specific prognostic indicators, and further justify our prognostic opinion.

Comorbid conditions are unrelated to the hospice diagnosis. We include comorbid conditions if they relate to and further justify the prognosis for a patient. Otherwise, comorbid conditions which do not add to prognosis are not mentioned.

Remember, we use population data, performance status, and disease-specific prognostic indicators to paint the picture of a patient in a certification of terminal illness.
The question is: “Who are we painting the picture for?”

Many people think we are painting the picture for Medicare, but this isn’t entirely true. Medicare uses Medicare Administrative Contractors to manage the Medicare Hospice Benefit. These contractors handle reimbursement, respond to inquiries, and review medical records for claims. They also establish the Local Coverage Determination and coordinate with Medicare.

Local Coverage Determination criteria, often called LCDs, are guidelines. They are a blueprint of what is important and what to include in our certification of terminal illness.

This map indicates which Medicare Administrative Contractor administers the home health, and hospice benefit across the United States. These are NGS, which stands for National Government Services incorporated; CGS, which stands for CGS Administrators LLC; and Palmetto.

Palmetto’s LCDs are rooted in the World Health Organization international classification of functioning, disability, and health. They integrate function and disease process, and give us the guidance for admission in a nice, neat little package.

NGS and CGS are two distinct Medicare Administrative Contractors. They have similar guidelines that are rooted in the National Hospice and Palliative Care Organization Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases. This was published in 1996. They have general criteria that are rooted in prognostic indicators, and they do not integrate function and disease state in the same way.

Palmetto uses the diagnosis and population data to make seven different LCDs. NGS and CGS have one general LCD. Despite the differences, we write certifications the same way.

For more information about how each Medicare Administrative Contractor interprets population data, performance status, and disease-specific indicators, go to the Medicare website, cms.gov, and search for LCDs for the contractor in your area.

Criteria and enrollment do not occur in a vacuum. Practice consultation etiquette. Use your referring physician as a resource. Pick up the phone. Seek his or her medical opinion on why this patient qualifies for hospice. This will strengthen your certification or recertification note. This is also a wonderful way to build a relationship with our community physicians, and garner their support.

If you have spoken to the referring physician, add this statement to your certification or recertification note: “I have reviewed the case with Dr. X, the specialist, who agrees that the patient’s prognosis is less than six months.”

Cases…

Now, let’s review some cases. I recommend you use bullet points to paint a clear and concise picture of your patient. This makes it easier to write, and easier for the Medicare adjudicators to review. I highly recommend thinking about cases for certification on a continuum.

In some cases, you will only need population data to justify the patient’s limited prognosis. In some, you will also need to stress function and performance to make your case. in others, you will have to do a deep dive and include prognostic indicators.

When Population Data is Sufficient…..

Let’s review a case that will model when population data is sufficient.

Doug is 62, and was diagnosed with metastatic pancreatic cancer in December of 2020. It is now July of 2021.

Can you admit Doug?

To review population data, I use this prognostic table for patients with metastatic cancer. It was updated in 2017, after reviewing all of the published phase 3 clinical trials for patients with stage 3 and stage 4 cancers who were receiving conventional chemotherapy. It does not include prognostic data for patients receiving immunotherapy. As treatments are always changing, it is imperative you consult with the patient’s oncologist to understand the bare perception of treatment eligibility and prognosis.
Back to Doug. The population data for metastatic pancreatic cancer has a prognosis from six to eleven months if the disease follows its normal course.

We know Doug was initially diagnosed in December of 2020. At the time of his certification, we are seven months after his diagnosis. Based on where he is in the typical experience in patients with metastatic pancreatic cancer, he will decline and die within the next six months based on population data only.

So, for his certification statement, I would write: “Doug, 62-year-old male, hospice diagnosis: Metastatic Pancreatic Cancer, diagnosed December of 2020.” Then, “In my medical opinion, I believe Doug’s prognosis is less than six months, if the illness runs its normal course.” Also, having spoken to his oncologist, I would write: “I have reviewed the case with Dr. X, his oncologist, who agrees that the patient’s prognosis is less than six months.”

Metastatic pancreatic cancer is an example of a diagnosis with a very limited prognosis, irrespective of the initial functional status of the patient. Therefore, we can use population data alone to justify admitting our patient to hospice care.

When Population Data is Not Sufficient…..

The next situation to think about is when the population data alone does not support a prognosis that would qualify for hospice. In these cases, function will be our deciding factor.

Sarah is an 81-year-old female who developed a hemorrhagic stroke a month ago. She has respiratory failure, and a tracheostomy tube was placed. Recently, she was weaned off the ventilator and started on room air. Due to her persistent dysphagia, she received a percutaneous gastrostomy tube. Even with these interventions, she has had no improvement.

Can you admit Sarah? The answer is yes, you can. For her disease process, a hemorrhagic stroke, population data is not sufficient. What we really need to focus on is her performance status.

I would write: “Sarah is an 81-year-old female, hospice diagnosis: Hemorrhagic CVA. Now, tracheostomy and feeding tube dependent. In one month, her palliative performance scale has dropped from 90% to 30% without any signs of improvement.” I would confirm my medical opinion that she has a prognosis of less than six months. And I would also write that the referring physician agrees.

When Disease-specific Prognostic Indicators are Required

What do we do if despite the population data and function, this isn’t enough? We need to do that deep dive into disease-specific prognostic indicators.

Robert is a 72-year-old male who has had diastolic heart failure for the past three years. Functionally, his palliative performance scale is 50%. He is short of breath, has had some weight gain, and has had recurrent longer hospitalizations, as the IV diuretic medications have not been as effective for him.

Can you admit Robert? The answer is yes.

Population data is not as helpful here, as survival with heart failure can be anywhere from weeks to years. Function isn’t sufficient either, as he can live for years with assistance from others. You need to include disease-specific prognostic indicators. Patients with New York Heart Association class 4 heart failure, increased water retention, shortness of breath, recurrent hospitalizations, and decreased responsiveness to diuretics, all indicate poor prognosis. Plus, Robert does not want to return to the hospital or be resuscitated. In my note, I would include all of these prognostic indicators to justify my medical statement that Robert has a prognosis of less than six months.

Nuances of Certification

There are some important situations we will highlight for certification and recertification.

Recertification

Let’s talk about how you recertify a patient.

After our initial certification, a patient will receive hospice care for up to 90 days, as long as we believe the patient’s prognosis hasn’t lengthened beyond six months. The first 90 days is known as the first benefit period. After 90 days, before the next benefit period begins, recertification is required.

The physician and team review the patient’s situation, then the physician writes a recertification note. This note is structured just like the note for the initial certification of terminal illness. You might expect that a patient on hospice care would continue to decline. But this is not a requirement. As long as they continue to have a prognosis of less than or equal to six months, they can be recertified.

After review and discussion with the team, if everyone agrees, a hospice physician must paint the picture, sign and date the recertification note. This does not require the signature of the attending physician. This recertification can be performed up to fifteen days before, or two days after the benefit period begins. Completion too early or too late will be considered a technical error. This may lead to the patient being ineligible for the hospice benefit.

After the second 90-day period, all recertifications require a face-to-face visit. Face-to-face visits can be completed by either the physician or a nurse practitioner. They are typically done at the home or at the bedside of the patient. Family may or may not be present. In some circumstances, a telehealth visit may be acceptable.

Once the face-to-face visit is complete, documentation of the visit is included along with the recertification note. The patient will now receive hospice care for an additional 60 days. After 60 days, a second face-to-face visit is required. This process can go on indefinitely. As Nancy DeParle said in her letter, quote, “As long as the physician continues to properly and conscientiously recertify the six-month prognosis…”

Can Patients Enrolled in Hospice Go on Vacation?

Now, what happens when patients receiving care under a Medicare hospice benefit want to go on vacation?

Back to Robert. He lives in Ohio. He and his family want to go to Sarasota, Florida for three weeks. However, he has enrolled in a Medicare hospice benefit.

Can Robert go on vacation?

Of course, he can. The Medicare hospice benefit aims to prevent and relieve suffering and promote quality of life for patients approaching the end of their lives. This insurance benefit allows patients to travel within the United States to have the best possible quality of life while they can. This unique benefit will allow Robert and his family to have the special vacation they’re all hoping for.

To ensure his needs are met while he is vacationing, the hospice in Ohio would contract with and transfer his care to a hospice in Florida. This does not require disenrollment. At the end of his vacation, they would then transfer Robert’s care back to the hospice in Ohio.

Stabilization

Now, we will look at a patient who has stabilized.

John is 67 years-old, and was diagnosed with prostate cancer in 2018. He has bulky lymphadenopathy, presumed to be metastatic cancer, a good appetite, and a palliative performance scale of 60%. He also has diabetes and hypertension.

Can you admit John?

Prostate cancer has a median survival of 49 months. The population data obviously is not enough here. When we look at his function, his palliative performance scale is 60%, which suggests a median survival of about 90 days.

You can admit John. For his certification note, I would write: “John, 67-year-old male. Hospice diagnosis: prostate cancer with metastatic lymphadenopathy diagnosed in 2018.” For his performance status and function, his palliative performance scale is 60%, down from 70% in the past month. Optimal symptom management with scheduled steroids and analgesics have kept him functional. I would then state that it is my medical opinion that his prognosis is less than six months. Because I spoke with his oncologist, I would also include his agreement with John’s prognosis.

Five months after John was admitted to hospice care, during his second benefit period, the team notes that he still has had no major changes. He is eating well, has a good appetite, and has gained ten pounds. His palliative performance scale remains at 60%. What do you do now?

Can you recertify John?

When we are reviewing a patient for recertification, we are reviewing his or her overall situation with the team. We know John was diagnosed three years ago. Since he enrolled in hospice, he has had no change in his function. He is eating well, and he has gained weight, without any change in the treatment plan. After stabilizing his situation, John has not had any additional needs. Given his situation, the team and I would be surprised if he were to die in the next six months. Based on this, I am obliged to discharge him from hospice services. I would tell him to call our team if he notices any significant changes.

So, we would discharge John during his second benefit period, and ensure appropriate professional follow up.

One year later, John calls our team concerned about a significant decline in his function. He has now lost 40 pounds, has no appetite, and his palliative performance scale has dropped to 40%. He is spending a lot of his time in bed, and now, needs family to assist him with bathing and dressing.

Can you admit John?

Yes, you can. For this readmission and recertification note, I would write: “John, 68-year-old male. Hospice diagnosis: metastatic prostate cancer. Forty pound weight loss in the past three months. No appetite in spite of family’s best effort. Palliative performance scale is now 40%, down from 60% in the previous month. Requires assistance with transferring, bathing, and dressing.” Then, state my medical opinion of John’s prognosis of less than six months.

When John is readmitted, the hospice benefit period does not start over again. He is now admitted into his third benefit period. This requires a face-to-face assessment to ensure he is again hospice appropriate.

After readmission, each subsequent benefit period is 60 days. Recertification always requires a face-to-face visit, discussion with the team, and a new note from a physician that clearly paints the picture of the patient’s situation.

Dementia

Last, let’s review a case of dementia.

Trudy is a 92-year-old female with Alzheimer’s dementia. She is a teetotaler, drinking tea and eating small bites of toast for the majority of her intake. She needs assistance for any transfers, and can only ambulate with significant assistance from a care giver, almost to the point of carrying her. She is incontinent of bowel and bladder. She is pleasant but confused, and only speaks two to three words on any given day, some of which are pretty hard to understand. Trudy also has a history of urinary tract infections, which have increased in frequency as her dementia worsens.

Can you certify Trudy for hospice?

This is the functional assessment staging, or FAST, for patients with Alzheimer’s dementia. When patients speak six words or fewer a day, their FAST score is 7a. Trudy fits this clinical picture.

For Trudy’s certification note, I would write: “Trudy, 92-year-old female. Hospice diagnosis: Alzheimer’s Dementia, FAST 7a. Her palliative performance scale is 40%. She typically eats less 25% of her meals, and continues to lose weight, and has decreased two sizes in her clothing. She has recurrent urinary tract infections. The goals that she and her surrogate have discussed are comfort-centered, with no hospitalizations or antibiotics to extend her life.”

I would then write: “In my medical opinion, I believe Trudy’s prognosis is less than six months if the illness runs its normal course.”

Medicare Scrutiny

The Medicare Administrative Contractors are responsible for ensuring that the hospice benefit is being used appropriately. Hospice administrators, physicians, nurse practitioners, and team members need to be aware of situations that will raise red flags when patient cases are being reviewed. Situations that might raise red flags and lead to more in-depth scrutiny include:

Are there a lot of patients with prolonged stays on hospice care? Are levels and settings of care being used appropriately? Is there an appropriate case mix of patients?

Why are patients being discharged from hospice care? Are medications that are related to the patient’s hospice diagnosis not being paid for by the hospice?

To ensure that people reviewing our certification and recertification notes understand each patient’s situation clearly, we need to document with conviction, paint a clear picture about the patient, and ensure you are technically correct.

Remember: prognostication is a prospective process. Our perception of each patient’s prognosis needs to be justified. For some patients, population data will be sufficient. For others, performance status will justify their limited prognosis. Frequently, we need to include specific prognostic indicators.

Educate your physicians and nurse practitioners about what is to be included in certification, recertification, and face-to-face notes. Ensure certification notes and team member documentation paint a similar picture. Never simply state that the patient is doing well, without highlighting how the hospice plan of care is helping them achieve their goals. Routinely review outliers who may be open to scrutiny with a panel of physicians and team members.

If you receive a denial for a patient admission, appeal it with more detail. If you receive a second denial, be prepared to justify your medical opinion to an administrative law judge. They are not doctors, and typically accept the opinion of the healthcare professional if it is well documented.

The most common reasons for sustained denials are technical errors, documentation that does not paint a clear clinical picture, or discordance between certification and team documentation.

Summary

In summary, early referral and compliance with the Medicare hospice benefit certification or recertification process helps to ensure patients and families get easy access to hospice care and minimize our risk of denials.