Living with LMRPs requires good documentation
Tell the patient’s clinical story to avoid denials
Now that local medical review policies (LMRPs) for non-cancer diagnoses have either been implemented by fiscal intermediaries or are in the process of being phased in, hospice providers must prove their patients meet LMRP criteria.
Fiscal intermediaries began implementing the eight disease-specific policies last September, leaving hospices little choice but to go along. Although the National Hospice Organization in Washington, DC, and fiscal intermediaries still are defining the term rapid decline, changes in wording will not change the fact that solid documentation of a patient’s condition and subsequent decline is required. (See related story on p. 41.)
Documenting patient condition and care for Medicare is nothing new, but experts say hospices must sharpen their documentation skills, especially with the Baltimore-based Health Care Financing Administration trying so hard to sniff out fraud and abuse. The development of LMRPs is a direct result of HCFA’s effort to make it more difficult for hospices to defraud the federal government. In the process, however, the work of honest hospices has become more difficult with the latest emphasis on documentation.
"The intent was to ensure appropriate admissions to hospice," says Margaret Clausen, CAE, executive director of the California State Hospice Association in Sacramento. "We also think it will help physicians make a diagnosis of six months or less to live and admit patients to hospice."
Why documentation is important
Hospices will be expected to use the LMRPs as guidelines for admitting patients with the eight diagnoses covered in the policies. Those are:
• HIV;
• pulmonary disease;
• heart disease;
• dementia;
• stroke and coma;
• liver disease;
• renal disease;
• amyotrophic lateral sclerosis.
The policies give specific tests and scales to be used in determining the prognosis before admitting a patient to hospice.
LMRPs will allow fiscal intermediaries to:
• Characterize their entire hospice provider populations.
• Target those providers who have the highest proportion of lengthy-stay, non-cancer patients compared to the fiscal intermediaries’ overall provider population.
• Focus medical review on appropriate providers.
As a result, hospices can expect to receive additional documentation requests from HCFA. Specifically, though, fiscal intermediaries will be looking for the following reasons for additional document requests (ADRs).
• The provider is already on a corrective action plan.
• The provider has a high non-cancer length of stay (NCLOS) rate relative to other hospice providers in the fiscal intermediary’s population.
• A beneficiary specific edit.
• A CFO edit.
Learning the hard way
As hospices improve their documentation, their goal should be to tighten documentation in admission criteria by being as specific and accurate as possible.
Hospice administrators at Hospice of Palm Beach County in West Palm Beach, FL, put their documentation to the test when the hospice was placed under focused medical review in 1998. The hospice survived the intense review of patient records with only 15% denials and learned first hand the required elements of solid documentation.
"We learned a lot by going through this process," says Susan Rasimas, RN, with Hospice of Palm Beach County. "We found that utilizing these [non-cancer diagnosis guidelines] in admission criteria is a winner. If you have this information in your chart they can’t deny you."
One lesson Rasimas learned was that without adequate documentation, even the most obvious cases still may lead to denials. "Even if a patient dies five days after admission, if you don’t have the proper documentation you still can be denied," she says.
Rasimas offers these tips for documentation success:
• Note the dates of service on the ADR request.
• Including any assessment from all disciplines involved in patient’s care to demonstrate an interdisciplinary approach.
• Include volunteer notes.
• Include chaplain’s notes.
• Book the order promptly.
• Obtain a verbal certification of terminal illness from the medical director within two days of admission or recertification.
• Obtain signed certification of terminal illness from medical director.
• Include supporting documentation, such as initial certification, pathology report, doctor’s orders and physician-ordered changes in medication, progress notes, home visit notes, etc.
• Include medical necessity documentation.
• Provide comparisons to show rapid or clinical decline.
Rasimas notes chart audits also are useful. Hospices should consider taking a sample of charts and reviewing them to see whether documentation of the above items meets the guidelines spelled out in each of the LMRPs.
Chart audits show trends in documentation errors common throughout the hospice and identify clinical staff who consistently fall short of the needed documentation standards, she explains.
"We went right into chart audits," Rasimas says. "We saw patterns, nurses who were generic documentors. You have to start doing chart audits on current records. If you notice system-wide problems, have an inservice."
Tell the patient’s story
Take the comparison requirement, for example. Simply noting a patient’s difficulty to swallow on two different occasions does not allow for a comparison to be made, she notes. However, a detailed description of how the difficulty has prevented the patient from eating properly and documenting the patient’s resulting caloric intake over time does meet the criteria.
"Very clearly they [HCFA] want comparisons," Rasimas says. "If your patient is O2 PRN and that is all you write in your notes, it doesn’t tell them anything. They want things that are measurable and comparable. For example, if your patient in the beginning is using O2 after he’s had a shower or gone to the mall because he’s exhausted, write that he used O2 after minimal exertion. Try to be as specific as you can.
"I like it when people start their notes by writing, Visited patient in own home. Found patient sitting in the chair watching TV.’ Right away you have a picture of someone who is up and dressed. You’ll start to see a story, not just notes."
Clausen provides this example of a nurses’ notes during a visit with a patient who fell under the heart disease LMRP:
"Heart disease: Increased dyspnea and chest pain with attempts at ambulation, relieved with morphine sulfate 25 mg prior to exertion."
The notation is sound because it includes the primary diagnosis and noted pain alleviation, Clausen notes. To further bolster the documentation, she suggests the writer reference the specific LMRP criteria which allows for admission or recertification.
Nurses, social workers, therapists, and chaplains are accustomed to taking notes and putting them in the patient chart. However, time is the enemy of accurate documentation. Failing to enter notes into a patient chart immediately following a patient visit creates the risk of forgetting details, which dulls the clarity of story the clinician is trying to portray, according to Rasimas.
The five "W’s" — who, what, where, when, and why — provide another angle in which to look at story telling in documentation. Like a reporter, hospice workers should look at their chart notes and supporting documentation to ensure those five elements are included.
For example, documentation must indicate the need for a specific discipline. The question is who delivered the care and why. Educational material provided to hospices in the wake of LMRPs by Woodland Hills-based fiscal intermediary Blue Cross of California suggest hospices document answers to the following:
• Who, which professional, a nurse, social worker, chaplain, physical therapist, rendered services?
• What services were provided under the treatment plan and the factors that led to any care outside the treatment plan?
• Why were services rendered necessary?
• When were services rendered, including date and time?
• Where did the care take place? If care took place in a setting other than the patient’s home, such as an emergency room, or inpatient hospice, document why.
In addition, the same Blue Cross of California guidelines note that telling the story in a manner that fiscal intermediaries will respond to requires hospices convey the following:
• evidence of patient decline as a result of the disease process;
• evidence of symptom control;
• evidence of terminal condition.
The fiscal intermediary says hospices must document care promptly. In addition, hospices must accurately record care that was ordered, the patient’s behavior toward care, the patient’s compliance with designated care, and rapid decline. Documentation should make it easy to identify the patients’ physical and emotional problems, environmental changes that effect treatment and other characteristics that have a bearing on treatment.
Hospices’ documentation should also be able to justify admission and recertification. This is done by recording any actions taken that are part of the patient’s plan of care, or supporting documentation, such as physician orders, for care that may be considered an addition to the original treatment plan, according to Blue Cross of California. Tests that may substantiate decline should also be included as well as the patient’s response or lack of response to treatment such as chemotherapy and radiation.
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