Hospice Clinical Documentation
嚜澤HPCO Spring Conference
05/23/2014
Hospice Clinical Documentation
Proving Hospice Regulatory Compliance
By Beth Noyce, RN, BSJMC, HCS-D COS-C
Copyright 2014
Hospice Clinical Documentation
? Course Objectives:
每 Successful course participants will learn to:
邦Recognize common documentation errors.
邦Discuss the implications of erroneous, inadequate or
untimely documentation.
邦Identify methods for improving documentation.
Hospice Clinical Documentation
? Hospice benefit available to
beneficiaries who:
每 Are entitled to Part-A
Medicare benefits;
每 Are certified as terminally
ill;
每 Elect the hospice benefit;
每 Knowingly waive other
certain Medicare benefits.
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AHPCO Spring Conference
05/23/2014
Hospice Clinical Compliance
? Hospice providers are
eligible for claim payment if
the patient record shows:
每 Beneficiary is eligible for
hospice services;
每 Services provided were
medically necessary;
每 Hospice provider met all
regulatory requirements.
HOSPICE COVERAGE
Hospice Coverage
? Technical requirements for hospice coverage:
每 Notice of Election (NOE)
? Prior to Hospice admission:
每 Certification of Terminal Illness (CTI)
? Required for each benefit period:
每 Face-to-Face Encounter documentation
? Required for each third and later benefit period.
2
AHPCO Spring Conference
05/23/2014
Hospice Coverage
? Clinical documentation requirement for
hospice coverage:
每 Patient record must support documentation in
technical elements.
? Terminal prognosis of 6 months or less
? LCD criteria
每 Days in any billing period without corresponding
documentation showing eligibility are unpaid.
IDG, CARE PLAN,
SERVICE COORDINATION
IDG, Care Plan, Service Coordination
? Approach to Service Delivery
每 IDG provides hospice care/services
每 Based on hospice patient/family needs
? Physical
? Medical
? Psychosocial
? Emotional
? Spiritual
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AHPCO Spring Conference
05/23/2014
IDG, Care Plan, Service Coordination
? Plan of Care
每All IDG members contribute
Pl a n
? Doctor of medicine or osteopathy
? Registered Nurse
? Social worker
? Pastoral or other counselor
每Involve any attending physician
IDG, Care Plan, Service Coordination
? Plan of Care
每Based on assessment assessments
? Initial, comprehensive, and updated
每Individualized
每Specifies care and services needed
? To meet patient and family-specific needs
? Related to the terminal illness and
related conditions.
IDG, Care Plan, Service Coordination
? Needs unrelated to terminal illness
每 Hospices not required to provide these services;
每 Must acknowledge, document who is addressing;
每 Medicare considers most conditions as
contributing to terminal illness;
每 Hospice physician must document why any
condition is not related.
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AHPCO Spring Conference
05/23/2014
IDG, Care Plan, Service Coordination
? Hospices must provide
virtually all care of
terminally ill patients:
每 Most problems are related
to the terminal illness.
每 All needed services are
considered related.
IDG, Care Plan, Service Coordination
? Care Plan Content
邦Pain and symptom management
interventions;
邦Scope and frequency of needed services;
邦Measurable outcomes anticipated;
邦Drugs and treatment needed;
邦Medical supplies and appliances needed;
IDG, Care Plan, Service Coordination
? IDG must document
patient＊s/representative＊s:
? Level of understanding the care
plan,
? Involvement in the care plan,
? Agreement with the care plan,
? In accordance with the
hospice's own policies.
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