Medicare Program; FY 2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements; and Updates on Payment Reform, 48233-48281 [2013-18838]
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Vol. 78
Wednesday,
No. 152
August 7, 2013
Part II
Department of Health and Human Services
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Center for Medicare & Medicaid Services
42 CFR Part 418
Medicare Program; FY 2014 Hospice Wage Index and Payment Rate
Update; Hospice Quality Reporting Requirements; and Updates on
Payment Reform; Final Rule
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Federal Register / Vol. 78, No. 152 / Wednesday, August 7, 2013 / Rules and Regulations
SUPPLEMENTARY INFORMATION:
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
42 CFR Part 418
[CMS–1449–F]
RIN 0938–AR64
Medicare Program; FY 2014 Hospice
Wage Index and Payment Rate Update;
Hospice Quality Reporting
Requirements; and Updates on
Payment Reform
Centers for Medicare &
Medicaid Services (CMS), HHS.
ACTION: Final rule.
AGENCY:
This final rule updates the
hospice payment rates and the wage
index for fiscal year (FY) 2014, and
continues the phase out of the wage
index budget neutrality adjustment
factor (BNAF). Including the FY 2014 15
percent BNAF reduction, the total 5 year
cumulative BNAF reduction in FY 2014
will be 70 percent. The BNAF phase-out
will continue with successive 15
percent reductions in FY 2015 and FY
2016. This final rule also clarifies how
hospices are to report diagnoses on
hospice claims, and provides updates to
the public on hospice payment reform.
Additionally, this final rule changes the
requirements for the hospice quality
reporting program by discontinuing
currently reported measures and
implementing a Hospice Item Set with
seven National Quality Forum (NFQ)
endorsed measures beginning July 1,
2014, as proposed. Finally, this final
rule will implement the hospice
Experience of Care Survey on January 1,
2015, as proposed.
DATES: Effective Date: These regulations
are effective on October 1, 2013.
FOR FURTHER INFORMATION CONTACT:
Debra Dean-Whittaker, (410) 786–0848,
for questions regarding the hospice
experience of care survey.
Robin Dowell, (410) 786–0060, for
questions regarding quality reporting
for hospices and collection of
information requirements.
Hillary Loeffler, (410) 786–0456, for
general questions about hospice
payment.
Katherine Lucas, (410) 786–7723 for
questions regarding payment reform.
Anjana Patel, (410) 786–2120, for
questions regarding the FY 2014
hospice wage index and payment
rates.
Kelly Vontran, (410) 786–0332, for
questions on diagnosis reporting on
hospice claims.
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SUMMARY:
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Wage Index Addenda: In the past, the
wage index addenda referred to in the
preamble of our proposed and final
rules were available in the Federal
Register. However, the wage index
addenda of the annual proposed and
final rules will no longer be available in
the Federal Register. Instead, these
addenda will be available only through
the internet on the CMS Web site at:
(https://www.cms.gov/Medicare/
Medicare-Fee-for-Service-Payment/
Hospice/.) Readers who
experience any problems accessing any
of the wage index addenda related to the
hospice payment rules that are posted
on the CMS Web site identified above
should contact Anjana Patel at 410–
786–2120.
Table of Contents
I. Executive Summary
A. Purpose
B. Summary of the Major Provisions
C. Summary of Costs, Benefits, and
Transfers
II. Background
A. Hospice Care
B. History of the Medicare Hospice Benefit
C. Services Covered by the Medicare
Hospice Benefit
D. Medicare Payment for Hospice Care
1. Omnibus Budget Reconciliation Act of
1989
2. Balanced Budget Act of 1997
3. FY 1998 Hospice Wage Index Final Rule
4. FY 2010 Hospice Wage Index Final Rule
5. The Affordable Care Act
6. FY 2012 Hospice Wage Index Final Rule
E. Trends in Medicare Hospice Utilization
III. Summary of the Provisions of the
Proposed Rule
A. Diagnosis Reporting on Hospice Claims
1. ICD–9–CM Coding Guidelines
2. Use of Nonspecific, Symptom Diagnoses
3. Use of ‘‘Mental, Behavioral and
Neurodevelopmental Disorders’’ ICD–9–
CM Codes
4. Guidance on Coding of Principal and
Other, Additional, and/or Co-Existing
Diagnoses
5. Transition to ICD–10–CM
B. Hospice Quality Reporting Program
C. FY 2014 Hospice Wage Index and Rates
Update
D. Update on Hospice Payment Reform and
Data Collection
E. Technical and Clarifying Regulatory
Text Change
IV. Analysis and Responses to Public
Comments
A. Diagnosis Reporting on Hospice Claims
1. ICD–9–CM Coding Guidelines
2. Use of Nonspecific, Symptom Diagnoses
3. Use of ‘‘Mental, Behavioral and
Neurodevelopmental Disorders’’ ICD–9–
CM Codes
4. Guidance on Coding of Principal and
Other, Additional, and/or Co-Existing
Diagnoses
5. Transition to ICD–10–CM
B. The Hospice Quality Reporting Program
1. Background and Statutory Authority
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2. Quality Measures for Hospice Quality
Reporting Program and Data Submission
Requirements for Payment Year FY 2014
3. Quality Measures for Hospice Quality
Reporting Program and Data Submission
Requirements for Payment Year FY 2015
and Beyond
4. Quality Measures for Hospice Quality
Reporting Program for Payment Year FY
2016 and Beyond
5. Public Availability of Data Submitted
6. The CMS Hospice Experience of Care
Survey for the FY 2017 Payment
Determination and That of Subsequent
Fiscal Years
7. Notice Pertaining to Reconsiderations
Following APU Determinations
C. FY 2014 Hospice Wage Index and Rates
Update
1. Hospice Wage Index
2. FY 2014 Wage Index With an Additional
15 Percent Reduced Budget Neutrality
Adjustment Factor (BNAF)
3. Hospice Payment Update Percentage
4. Final FY 2014 Hospice Payment Rates
D. Update on Hospice Payment Reform and
Data Collection
1. Update on Reform Options
a. Rebasing the Routine Home Care (RHC)
Rate
b. Site of Service Adjustment for Hospice
Patients in Nursing Facilities
2. Reform Research Findings
3. Additional Data Collection
E. Technical and Clarifying Regulatory
Text Change
V. Collection of Information Requirements
VI. Regulatory Impact Analysis
A. Statement of Need
B. Overall Impact
1. Introduction
2. Detailed Economic Analysis
3. Cost Allocation of Quality Reporting
4. Alternatives Considered
C. Accounting Statement
D. Conclusion
1. Regulatory Flexibility Act Analysis
2. Unfunded Mandates Reform Act
Analysis
VII. Federalism Analysis and Regulations
Text
Acronyms
Because of the many terms to which
we refer by acronym in this final rule,
we are listing the acronyms used and
their corresponding meanings in
alphabetical order below:
APU Annual Payment Update
BBA Balanced Budget Act of 1997
BLS Bureau of Labor Statistics
BMI Body Mass Index
BNAF Budget Neutrality Adjustment Factor
CAD Coronary Artery Disease
CAHPS® Consumer Assessment of
Healthcare Providers and Systems
CBSA Core-Based Statistical Area
CCW Chronic Conditions Warehouse
CFR Code of Federal Regulations
CHC Continuous Home Care
CMS Centers for Medicare & Medicaid
Services
COPD Chronic Obstructive Pulmonary
Disease
CoPs Conditions of Participation
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CR Change Request
CVA Cerebrovascular Accident
CY Calendar Year
DME Durable Medical Equipment
FEHC Family Evaluation of Hospice Care
FR Federal Register
FY Fiscal Year
GAO Government Accountability Office
GIP General Inpatient Care
HCFA Healthcare Financing Administration
HHS Health and Human Services
HIS Hospice Item Set
HQRP Hospice Quality Reporting Program
ICD–9–CM International Classification of
Diseases, Ninth Revision, Clinical
Modification
ICD–10–CM International Classification of
Diseases, Tenth Revision, Clinical
Modification
IDG Interdisciplinary Group
IPPS Inpatient Prospective Payment System
IRC Inpatient Respite Care
LCD Local Coverage Determination
LUPA Low Utilization Payment Amount
MAP Measure Applications Partnership
MedPAC Medicare Payment Advisory
Commission
MFP Multi-factor Productivity
MSA Metropolitan Statistical Area
NEC Not Elsewhere Classified
NF Long Term Care Nursing Facility
NPI National Provider Identifier
NQF National Quality Forum
OACT Office of the Actuary
OIG Office of Inspector General
OMB Office of Management and Budget
PEACE Prepare, Embrace, Attend,
Communicate, and Empower
PRA Paperwork Reduction Act
PRRB Provider Reimbursement Review
Board
QAPI Quality Assessment and Performance
Improvement
RFA Regulatory Flexibility Act
RHC Routine Home Care
SBA Small Business Administration
SNF Skilled Nursing Facility
TEFRA Tax Equity and Fiscal
Responsibility Act of 1982
TEP Technical Expert Panel
I. Executive Summary
A. Purpose
This final rule updates the payment
rates for hospice providers for fiscal
year (FY) 2014 as required under section
1814 (i) of the Social Security Act (the
Act). The updates incorporate the use of
updated hospital wage index data, the
5th year of the 7-year Budget Neutrality
Adjustment Factor (BNAF) phase-out,
and an update to the hospice payment
rates by the hospice payment update
percentage. Additionally, this final rule
clarifies diagnosis reporting on hospice
claims, provides an update on hospice
payment reform and additional data
collection requirements, and makes
changes to the quality reporting
requirements for hospice providers.
B. Summary of the Major Provisions
In this final rule we update the
hospice payment rates for FY 2014 by
1.7 percent as described in section
IV.C.3. We also update the FY 2014
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hospice wage index with more current
wage data, and the BNAF will be
reduced by an additional 15 percent for
a total BNAF reduction of 70 percent as
described in section IV.C.3. The August
6, 2009 FY 2010 Hospice Wage Index
final rule (74 FR 39384) finalized a 10
percent reduced BNAF for FY 2010 as
the first year of a 7-year phase-out of the
BNAF, to be followed by an additional
15 percent per year reduction in the
BNAF in each of the next 6 years. The
total BNAF phase-out will be complete
by FY 2016. This final rule also clarifies
diagnosis reporting on hospice claims,
especially regarding the use of nonspecific symptom diagnoses; provides
an update on hospice payment reform
and additional data collection
requirements; and finalizes a technical
regulations text change. Additionally,
this final rule changes the requirements
for the hospice quality reporting
program by discontinuing currently
reported measures and implementing a
Hospice Item Set with seven National
Quality Forum (NQF) endorsed
measures beginning July 1, 2014, as
proposed. Finally, this final rule will
implement the hospice Experience of
Care Survey on January 1, 2015, as
proposed.
C. Summary of Costs, Benefits, and
Transfers
Provision description
Total
FY 2014 Hospice Payment Rate Update ...........
The overall economic impact of this final rule is an estimated $160 million in increased payments to hospices.
The total cost to hospice providers, for submitting data to the Hospice Item Set starting in July
2014, is $14.3 million.
Costs for Hospices to Submit Data ....................
II. Background
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A. Hospice Care
Coping with a life-limiting illness can
be an overwhelming experience,
physically, emotionally and spiritually,
for both the person and his or her
family. Recognition that the care needs
at end-of-life are different from other
health care needs is a foundation of the
Medicare Hospice Benefit. Hospice is a
compassionate care philosophy and
practice for those who are terminally ill.
It is a holistic approach to treatment that
recognizes that the impending death of
an individual warrants a change from
curative to palliative care. Palliative
care means ‘‘patient and family-centered
care that optimizes quality of life by
anticipating, preventing, and treating
suffering. Palliative care throughout the
continuum of illness involves
addressing physical, intellectual,
emotional, social, and spiritual needs
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and to facilitate patient autonomy,
access to information, and choice’’ (42
CFR 418.3). Palliative care is at the core
of hospice philosophy and care
practices. The person beginning hospice
care, or his or her representative, needs
to understand that his or her illness is
no longer responding to medical
interventions to cure or slow the
progression of disease and then must
choose to stop further curative attempts
while palliative care continues and
intensifies, as needed, for continued
symptom management. As we stated in
the June 5, 2008 Hospice Conditions of
Participation final rule (73 FR 32088),
palliative care is an approach that
‘‘optimizes quality of life by
anticipating, preventing, and treating
suffering.’’ The goal of palliative care in
hospice is to improve the quality of life
of individuals and their families facing
the issues associated with lifethreatening illness through the
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prevention and relief of suffering by
means of early identification,
assessment and treatment of pain and
other issues. In addition, palliative care
in hospice includes coordinating care
services, reducing unnecessary
diagnostics or ineffective therapies, and
offering ongoing conversations with
individuals and their families about
changes in the disease and shifts in the
plan of care to meet the changing needs
with disease progression as the
individual approaches the end-of-life.
Medicare hospice care is palliative
care for individuals with a prognosis of
living 6 months or less if the terminal
illness runs its normal course. As
generally accepted by the medical
community, the term ‘‘terminal illness’’
refers to an advanced and progressively
deteriorating illness, and the illness is
diagnosed as incurable. When an
individual is terminally ill, many health
problems are brought on by underlying
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condition(s), as bodily systems are
interdependent. In the June 5, 2008
Hospice Conditions of Participation
final rule (73 FR 32088), we stated ‘‘the
medical director must consider the
primary terminal condition, related
diagnoses, current subjective and
objective medical findings, current
medication and treatment orders, and
information about unrelated conditions
when considering the initial
certification of the terminal illness.’’ As
referenced in our regulations at 42 CFR
418.22(b)(1), to be eligible for Medicare
hospice services, the beneficiary’s
attending physician (if any) and the
hospice medical director must certify
that the individual is terminally ill, that
is, the individual’s prognosis is for a life
expectancy of 6 months or less if the
terminal illness runs its normal course
as defined in section 1861(dd)(3)(A) of
the Act and our regulations at § 418.3.
The certification of terminal illness
must include a brief narrative
explanation of the clinical findings that
supports a life expectancy of 6 months
or less as part of the certification and
recertification forms as stated in
§ 418.22(b)(3).
The goal of hospice care is to make
the hospice patient as physically and
emotionally comfortable as possible,
with minimal disruption to normal
activities, while remaining primarily in
the home environment. Hospice care
uses an interdisciplinary approach to
deliver medical, nursing, social,
psychological, emotional, and spiritual
services through the use of a broad
spectrum of professional and other
caregivers and volunteers. While the
goal of hospice care is to allow for the
individual to remain in his or her home
environment, circumstances during the
end-of-life may necessitate short-term
inpatient admission to a hospital,
skilled nursing facility (SNF), or hospice
facility for procedures necessary for
pain control or acute or chronic
symptom management that cannot be
managed in any other setting. These
acute hospice care services are to ensure
that any new or worsening symptoms
are intensively addressed so that the
individual can return to his or her home
environment under routine hospice
care. Short-term, intermittent, inpatient
respite services are also available to the
family of the hospice patient when
needed to relieve the family or other
caregivers. Additionally, an individual
can receive continuous home care
during a period of crisis in which an
individual requires primarily
continuous nursing care to achieve
palliation or management of acute
medical symptoms so that the
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individual can remain at home.
Continuous home care may be covered
on a continuous basis for as much as 24
hours a day, and these periods must be
predominantly nursing care per our
regulations at § 418.204. A minimum of
8 hours of care must be furnished on a
particular day to qualify for the
continuous home care rate
(§ 418.302(e)(4)).
B. History of the Medicare Hospice
Benefit
Before the creation of the Medicare
Hospice Benefit, hospice was originally
run by volunteers who cared for the
dying. During the early development
stages of the Medicare Hospice Benefit,
hospice advocates, working with
legislators, were clear that they wanted
a Medicare benefit available that
provided all-inclusive care for
terminally-ill individuals, provided
pain relief and symptom management,
and offered the opportunity to die with
dignity in the comfort of one’s home
rather than in an institutional setting.1
As stated in the August 22, 1983
proposed rule entitled ‘‘Medicare
Program; Hospice Care’’ (48 FR 38146),
‘‘the hospice experience in the United
States has placed emphasis on home
care. It offers physician services,
specialized nursing services, and other
forms of care in the home to enable the
terminally ill individual to remain at
home in the company of family and
friends as long as possible.’’ The
concept of a beneficiary ‘‘electing’’ the
hospice benefit and being certified as
terminally ill were two key components
in the legislation responsible for the
creation of the Medicare Hospice
Benefit (section 122 of the Tax Equity
and Fiscal Responsibility Act of 1982
(TEFRA), (Pub. L. 97–248)). Section 122
of TEFRA created the Medicare Hospice
Benefit, which was implemented on
November 1, 1983. Under section
1861(dd) of the Social Security Act (the
Act), codified at 42 U.S.C. 1395x(dd),
we provide coverage of hospice care for
terminally ill Medicare beneficiaries
who elected to receive care from a
Medicare-certified hospice. Our
regulations at § 418.54(c) stipulate that
the comprehensive hospice assessment
must identify the patient’s physical,
psychosocial, emotional, and spiritual
needs related to the terminal illness and
related conditions, and address those
needs in order to promote the hospice
patient’s well-being, comfort, and
dignity throughout the dying process.
The comprehensive assessment must
1 Connor, Stephen (2007). Development of
Hospice and Palliative Care in the United States.
OMEGA. 561(1), p. 89–99.
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take into consideration the following
factors: the nature and condition
causing admission (including the
presence or lack of objective data and
subjective complaints); complications
and risk factors that affect care
planning; functional status; imminence
of death; and severity of symptoms. The
Medicare Hospice Benefit requires the
hospice to cover all reasonable and
necessary palliative care related to the
terminal prognosis and related
conditions, as described in the patient’s
plan of care. The December 16, 1983
Hospice final rule (48 FR 56008)
requires hospices to cover care for
interventions to manage pain and
symptoms. Clinically, related conditions
are any physical or mental conditions
that are related to or caused by either
the terminal illness or the medications
used to manage the terminal illness.2
Additionally, the hospice Conditions of
Participation at § 418.56(b), hospice
must provide all services necessary for
the palliation and management of the
terminal illness, related conditions and
interventions to manage pain and
symptoms. Therapy and interventions
must be assessed and managed in terms
of providing palliation and comfort
without undue symptom burden for the
hospice patient or family.3 For example,
a hospice patient with lung cancer (the
terminal illness) may receive inhalants
for shortness of breath (related to the
terminal condition). The patient may
also suffer from metastatic bone pain (a
related condition) and would be treated
with opioid analgesics. As a result of the
opioid therapy, the patient may suffer
from constipation (an associated
symptom) and require a laxative for
symptom relief. It is often not a single
diagnosis that represents the terminal
prognosis of the patient, but the
combined effect of several conditions
that makes the patient’s condition
terminal. We are restating what we
communicated in the December 16,
1983 Hospice final rule (48 FR 56010),
regarding what is related versus
unrelated to the terminal illness: ‘‘. . .
we believe that the unique physical
condition of each terminally ill
individual makes it necessary for these
decisions to be made on a case-by-case
basis. It is our general view that
hospices are required to provide
virtually all the care that is needed by
terminally ill patients.’’ Therefore,
unless there is clear evidence that a
2 Harder, PharmD, CGP, Julia. (2012). To Cover or
Not To Cover: Guidelines for Covered Medications
in Hospice Patients. The Clinician. 7(2), p. 1–3.
3 Paolini, DO, Charlotte. (2001). Symptoms
Management at End of Life. JAOA. 101(10). p. 609–
615.
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condition is unrelated to the terminal
prognosis, all services would be
considered related. It is also the
responsibility of the hospice physician
to document why a patient’s medical
needs would be unrelated to the
terminal prognosis.
The fundamental premise upon which
the hospice benefit was designed was
the ‘‘revocation’’ of traditional curative
care and the ‘‘election’’ of hospice care
for end-of-life symptom management
and maximization of quality of life, as
stated in the December 16,1983 Hospice
final rule (48 FR 56008). After electing
hospice care, the patient typically
returns to the home from an
institutionalized setting or remains in
the home, to be surrounded by family
and friends, and to prepare emotionally
and spiritually for death while receiving
expert symptom management and other
supportive services. Election of hospice
care also includes waiving the right to
Medicare payment for curative
treatment for the terminal prognosis,
and instead receiving palliative care to
manage pain or symptoms.
The benefit was originally designed to
cover hospice care for a finite period of
time that roughly corresponded to a life
expectancy of 6 months or less. Initially,
beneficiaries could receive three
election periods: Two 90-day periods
and one 30-day period. Currently,
Medicare beneficiaries can elect hospice
care for two 90-day periods and an
unlimited number of subsequent 60-day
periods; however, the expectation
remains that beneficiaries have a life
expectancy of 6 months or less if the
terminal illness runs its normal course.
C. Services Covered by the Medicare
Hospice Benefit
One requirement for coverage under
the Medicare Hospice Benefit is that
hospice services must be reasonable and
necessary for the palliation and
management of the terminal illness and
related conditions. Section 1861(dd)(1)
of the Act establishes the services that
are to be rendered by a Medicare
certified hospice program. These
covered services include: Nursing care;
physical therapy; occupational therapy;
speech-language pathology therapy;
medical social services; home health
aide services (now called hospice aide
services); physician services;
homemaker services; medical supplies
(including drugs and biologics); medical
appliances; counseling services
(including dietary counseling); shortterm inpatient care (including both
respite care and procedures necessary
for pain control and acute or chronic
symptom management) in a hospital,
nursing facility, or hospice inpatient
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facility; continuous home care during
periods of crisis and only as necessary
to maintain the terminally ill individual
at home; and any other item or service
which is specified in the plan of care
and for which payment may otherwise
be made under Medicare, in accordance
with Title XVIII of the Act.
Section 1814(a)(7)(B) of the Act
requires that a written plan for
providing hospice care to a beneficiary
who is a hospice patient be established
before care is provided by, or under
arrangements made by, that hospice
program and that the written plan be
periodically reviewed by the
beneficiary’s attending physician (if
any), the hospice medical director, and
an interdisciplinary group (described in
section 1861(dd)(2)(B) of the Act).
The services offered under the
hospice benefit must be available, as
needed, to beneficiaries 24 hours a day,
7 days a week (section 1861(dd)(2)(A)(i)
of the Act). Upon the implementation of
the hospice benefit, the Congress
expected hospices to continue to use
volunteer services, though these
services are not to be reimbursed (see
Section 1861(dd)(2)(E) of the Act and 48
FR 38149). The hospice
interdisciplinary group should be
comprised of paid hospice employees as
well as hospice volunteers, as stated in
the August 22, 1983 Hospice proposed
rule (48 FR 38149). This expectation is
in line with the history of hospice and
philosophy of holistic, comprehensive,
compassionate, end-of-life care.
The National Hospice Study was
initiated in 1980 through a grant
sponsored by the Robert Wood Johnson
and John A. Hartford Foundations and
CMS (formerly, the Health Care
Financing Administration (HCFA)). The
study was conducted between October
1980 and March 1983. The study
summarized the hospice care
philosophy as the following:
• Patient and family know of the
terminal condition.
• Further medical treatment and
intervention are indicated only on a
supportive basis.
• Pain control should be available to
patients as needed to prevent rather
than to just ameliorate pain.
• Interdisciplinary teamwork is
essential in caring for patient and
family.
• Family members and friends should
be active in providing support during
the death and bereavement process.
• Trained volunteers should provide
additional support as needed.
In the August 22, 1983 Hospice
proposed rule (48 FR 38149), we stated
‘‘the hospice benefit and the resulting
Medicare reimbursement is not
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intended to diminish the voluntary
spirit of hospices’’.
D. Medicare Payment for Hospice Care
Sections 1812(d), 1813(a)(4),
1814(a)(7), 1814(i), and 1861(dd) of the
Act, and our regulations in part 418,
establish eligibility requirements,
payment standards and procedures,
define covered services, and delineate
the conditions a hospice must meet to
be approved for participation in the
Medicare program. Part 418, subpart G,
provides for a per diem payment in one
of four prospectively-determined rate
categories of hospice care (routine home
care, continuous home care, inpatient
respite care, and general inpatient care),
based on each day a qualified Medicare
beneficiary is under hospice care (once
the individual has elected it). This per
diem payment is to include all of the
hospice services needed to manage the
beneficiaries’ care, as required by
section 1861(dd)(1) of the Act. There
has been little change in the hospice
payment structure since the benefit’s
inception. The per diem rate based on
level of care was established in 1983,
and this payment structure remains
today with some adjustments, as noted
below:
1. Omnibus Budget Reconciliation Act
of 1989
Section 6005(a) of the Omnibus
Budget Reconciliation Act of 1989 (Pub.
L 101–239) amended section
1814(i)(1)(C) of the Act and provided for
the following two changes in the
methodology concerning updating the
daily payment rates: (1) Effective
January 1, 1990, the daily payment rates
for routine home care and other services
in included in hospice care were
increased to equal 120 percent of the
rates in effect on September 30, 1989;
and (2) the daily payment rate for
routine home care and other services
included in hospice care for fiscal years
beginning on or after October 1, 1990,
were the payment rates in effect during
the previous Federal fiscal year
increased by the hospital market basket
percentage increase.
2. Balanced Budget Act of 1997
Section 4441(a) of the Balanced
Budget Act of 1997 (BBA) (Pub. L 105–
33) amended section 1814(i)(1)(C)(ii)(VI)
of the Act to establish updates to
hospice rates for FYs 1998 through
2002. Hospice rates were updated by a
factor equal to the hospital market
basket percentage increase, minus 1
percentage point. Payment rates for FYs
from 2002 have been updated according
to section 1814(i)(1)(C)(ii)(VII) of the
Act, which states that the update to the
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payment rates for subsequent FYs will
be the hospital market basket percentage
increase for the FY. The Social Security
Act requires us to use the inpatient
hospital market basket to determine
hospice payment rates.
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3. FY 1998 Hospice Wage Index Final
Rule
In the August 8, 1997 FY 1998
Hospice Wage Index final rule (62 FR
42860), we implemented a new
methodology for calculating the hospice
wage index based on the
recommendations of a negotiated
rulemaking committee. The original
hospice wage index was based on 1981
Bureau of Labor Statistics hospital data
and had not been updated since 1983.
In 1994, because of disparity in wages
from one geographical location to
another, the Hospice Wage Index
Negotiated Rulemaking Committee was
formed to negotiate a new wage index
methodology that could be accepted by
the industry and the government. This
Committee was comprised of
representatives from national hospice
associations; rural, urban, large and
small hospices, and multi-site hospices;
consumer groups; and a government
representative. The Committee decided
that in updating the hospice wage
index, aggregate Medicare payments to
hospices would remain budget neutral
to payments calculated using the 1983
wage index, to cushion the impact of
using a new wage index methodology.
To implement this policy, a BNAF
would be computed and applied
annually to the pre-floor, prereclassified hospital wage index when
deriving the hospice wage index, subject
to a wage index floor.
4. FY 2010 Hospice Wage Index Final
Rule
Inpatient hospital pre-floor and prereclassified wage index values, as
described in the August 8, 1997 Hospice
Wage Index final rule are subject to
either a budget neutrality adjustment or
application of the wage index floor.
Wage index values of 0.8 or greater are
adjusted by the budget neutrality
adjustment factor (BNAF). Starting in
FY 2010, a 7-year phase-out of the
BNAF began (August 6, 2009 FY 2010
Hospice Wage Index final rule (74 FR
39384), with a 10 percent reduction in
FY 2010, and additional 15 percent
reduction for a total of 25 percent in FY
2011, an additional 15 percent
reduction for a total 40 percent in FY
2012, and an additional 15 percent
reduction for a total of 55 percent in FY
2013. The phase-out will continue with
an additional 15 percent reduction for a
total reduction of 70 percent in FY 2014,
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an additional 15 percent reduction for a
total reduction of 85 percent in FY 2015,
and an additional 15 percent reduction
for complete elimination in FY 2016.
We note that the BNAF is an
adjustment, which increases the hospice
wage index value. Therefore, the BNAF
reduction is a reduction in the amount
of the BNAF increase applied to the
hospice wage index value. It is not a
reduction in the hospice wage index
value, or in the hospice payment rates.
5. The Affordable Care Act
Starting with FY 2013 (and in
subsequent FYs), the market basket
percentage update under the hospice
payment system referenced in sections
1814(i)(1)(C)(ii)(VII) and
1814(i)(1)(C)(iii) of the Act will be
annually reduced by changes in
economy-wide productivity, as
specified in section 1886(b)(3)(B)(xi)(II)
of the Act, as amended by section
3132(a) of the Patient Protection and
Affordable Care Act of 2010 (Pub. L.
111–148) as amended by the Health
Care and Education Reconciliation Act
of 2010 (Pub. L. 111–152) (the
Affordable Care Act)). In FY 2013
through FY 2019, the market basket
percentage update under the hospice
payment system will be reduced by an
additional 0.3 percentage point
(although for FY 2014 to FY 2019, the
potential 0.3 percentage point reduction
is subject to suspension under
conditions as specified in section
1814(i)(1)(C)(v) of the Act).
In addition, sections 1814(i)(5)(A)
through (C) of the Act, as amended by
section 3132(a) of the Affordable Care
Act, require hospices to begin
submitting quality data, based on
measures to be specified by the
Secretary, for FY 2014 and subsequent
fiscal years. Beginning in FY 2014,
hospices which fail to report quality
data will have their market basket
update reduced by 2 percentage points.
Section 1814(a)(7)(D)(i) of the Act was
amended by section 3132 (b)(2)(D)(i) of
the Affordable Care Act, and requires,
effective January 1, 2011, that a hospice
physician or nurse practitioner have a
face-to-face encounter with an
individual to determine continued
eligibility of the individual for hospice
care prior to the 180th-day
recertification and each subsequent
recertification and attest that such visit
took place. When implementing this
provision, we decided that the 180thday recertification and subsequent
recertifications corresponded to the
recertification for a beneficiary’s third or
subsequent benefit periods (August 4,
2011 FY 2012 Hospice Wage Index final
rule (76 FR 47314)).
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Further, section 1814(i)(6) of the Act,
as amended by section 3132(a)(1)(B) of
the Affordable Care Act, authorizes the
Secretary to collect additional data and
information determined appropriate to
revise payments for hospice care and
other purposes. The types of data and
information suggested in the Affordable
Care Act would capture accurate
resource utilization, which could be
collected on claims, cost reports, and
possibly other mechanisms, as the
Secretary determines to be appropriate.
The data collected may be used to revise
the methodology for determining the
payment rates for routine home care and
other services included in hospice care,
no earlier than October 1, 2013, as
described in section 1814(i)(6)(D) of the
Act. In addition, we are required to
consult with hospice programs and the
Medicare Payment Advisory
Commission (MedPAC) regarding
additional data collection and payment
revision options.
6. FY 2012 Hospice Wage Index Final
Rule
When the Medicare Hospice Benefit
was implemented, the Congress
included an aggregate cap on hospice
payments, which limits the total
aggregate payments any individual
hospice provider can receive in a year.
The Congress stipulated that a ‘‘cap
amount’’ be computed each year. The
cap amount was set at $6,500 per
beneficiary when first enacted in 1983
and is adjusted annually by the change
in the medical care expenditure
category of the consumer price index for
urban consumers from March 1984 to
March of the cap year (section
1814(i)(2)(B) of the Act). The cap year is
defined as the period from November
1st to October 31st. As we stated in the
August 4, 2011 FY 2012 Hospice Wage
Index final rule (76 FR 47308 through
47314), for the 2012 cap year and
subsequent cap years, the hospice
aggregate cap will be calculated using
the patient-by-patient proportional
methodology, within certain limits. We
will allow existing hospices the option
of having their cap calculated via the
original streamlined methodology, also
within certain limits. New hospices will
have their cap determinations
calculated using the patient-by-patient
proportional methodology. The patientby-patient proportional methodology
and the streamlined methodology are
two different methodologies for
counting beneficiaries when calculating
the hospice aggregate cap. A detailed
explanation of these methods is found
in the August 4, 2011 FY 2012 Hospice
Wage Index final rule (76 FR 47308
through 47314). If a hospice’s total
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Medicare reimbursement for the cap
year exceeded the hospice aggregate
cap, then the hospice would have to
repay the excess back to Medicare.
E. Trends in Medicare Hospice
Utilization
Since the implementation of the
hospice benefit in 1983, and especially
within the last decade, there has been
substantial growth in hospice
utilization. The number of Medicare
beneficiaries receiving hospice services
has grown from 513,000 in FY 2000 to
over 1.3 million in FY 2012. Similarly,
Medicare hospice expenditures have
risen from $2.9 billion in FY 2000 to
$14.7 billion in FY 2012. Our Office of
the Actuary (OACT) projects that
hospice expenditures are expected to
continue to increase by approximately 8
percent annually, reflecting an increase
in the number of Medicare beneficiaries,
more beneficiary awareness of the
Medicare Hospice Benefit for end-of-life
care, and a growing preference for care
provided in home and communitybased settings. However, this increased
spending is partly due to an increased
average lifetime length of stay for
beneficiaries, from 54 days in 2000 to 86
days in FY 2010, an increase of 59
percent.
There have also been noted changes
in the diagnosis patterns among
48239
Medicare hospice enrollees, with a
growing percentage of beneficiaries with
non-cancer diagnoses. Specifically,
there were notable increases between
2002 and 2007 in neurologically-based
diagnoses, including various dementia
diagnoses. Additionally, there have
been significant increases in the use of
non-specific, symptom-classified
diagnoses, such as ‘‘debility’’ and ‘‘adult
failure to thrive.’’ In FY 2012, both
‘‘debility’’ and ‘‘adult failure to thrive’’
were in the top five claims-reported
hospice diagnoses and were the first and
third most common hospice diagnoses,
respectively (see Table 2 below).
TABLE 2—THE TOP TWENTY PRINCIPAL HOSPICE DIAGNOSES, FY 2002, FY 2007, FY 2012
Rank
ICD–9/Reported principal diagnosis
Year: 2002
1 ........................
2 ........................
3 ........................
4 ........................
5 ........................
6 ........................
7 ........................
8 ........................
9 ........................
10 ......................
11 ......................
12 ......................
13 ......................
14 ......................
15 ......................
16 ......................
17 ......................
18 ......................
19 ......................
20 ......................
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1
2
3
4
........................
........................
........................
........................
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73,769
45,951
36,999
35,197
28,787
26,897
20,262
18,304
17,812
16,999
16,379
15,427
10,394
10,332
8,956
8,865
8,764
8,599
7,432
6,916
799.3
162.9
783.7
428.0
90,150
86,954
77,836
60,815
58,303
58,200
37,667
31,800
22,170
22,086
20,378
19,082
19,080
17,697
16,524
15,777
12,188
11,196
8,806
8,434
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9
8
7
6
6
6
4
3
2
2
2
2
2
2
2
2
1
1
1
1
161,163
89,636
86,467
84,333
12
7
7
6
Total Patients = 1,328,651
Debility Unspecified ..............................................................................................
Lung Cancer .........................................................................................................
Adult Failure To Thrive ........................................................................................
Congestive Heart Failure .....................................................................................
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11
7
6
5
4
4
3
3
3
3
2
2
2
2
1
1
1
1
1
1
Total Patients = 1,039,099
799.3 Debility Unspecified ................................................................................................
162.9 Lung Cancer .........................................................................................................
428.0 Congestive Heart Failure .....................................................................................
496 COPD ......................................................................................................................
783.7 Adult Failure To Thrive ........................................................................................
331.0 Alzheimer’s Disease .............................................................................................
290.0 Senile Dementia Uncomp. ...................................................................................
436 CVA/Stroke ..............................................................................................................
429.9 Heart Disease Unspecified ..................................................................................
185 Prostate Cancer ......................................................................................................
174.9 Breast Cancer ......................................................................................................
157.9 Pancreas Unspecified ..........................................................................................
153.9 Colon Cancer .......................................................................................................
294.8 Organic Brain Syndrome NEC .............................................................................
332.0 Parkinson’s Disease .............................................................................................
294.10 Dementia In Other Diseases w/o Behav. Dist. ..................................................
586 Renal Failure Unspecified .......................................................................................
585.6 End Stage Renal Disease ....................................................................................
188.9 Bladder Cancer ....................................................................................................
183.0 Ovarian Cancer ....................................................................................................
Year: 2012
Percentage
Total Patients = 663,406
162.9 Lung Cancer .........................................................................................................
428.0 Congestive Heart Failure .....................................................................................
799.3 Debility Unspecified ..............................................................................................
496 COPD ......................................................................................................................
331.0 Alzheimer’s Disease .............................................................................................
436 CVA/Stroke ..............................................................................................................
185 Prostate Cancer ......................................................................................................
783.7 Adult Failure To Thrive ........................................................................................
174.9 Breast Cancer ......................................................................................................
290.0 Senile Dementia, Uncomp. ..................................................................................
153.0 Colon Cancer .......................................................................................................
157.9 Pancreatic Cancer ................................................................................................
294.8 Organic Brain Synd Nec ......................................................................................
429.9 Heart Disease Unspecified ..................................................................................
154.0 Rectosigmoid Colon Cancer ................................................................................
332.0 Parkinson’s Disease .............................................................................................
586 Renal Failure Unspecified .......................................................................................
585 Chronic Renal Failure (End 2005) ..........................................................................
183.0 Ovarian Cancer ....................................................................................................
188.9 Bladder Cancer ....................................................................................................
Year: 2007
1 ........................
2 ........................
3 ........................
4 ........................
5 ........................
6 ........................
7 ........................
8 ........................
9 ........................
10 ......................
11 ......................
12 ......................
13 ......................
14 ......................
15 ......................
16 ......................
17 ......................
18 ......................
19 ......................
20 ......................
Total patients
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TABLE 2—THE TOP TWENTY PRINCIPAL HOSPICE DIAGNOSES, FY 2002, FY 2007, FY 2012—Continued
Rank
ICD–9/Reported principal diagnosis
Total patients
5 ........................
6 ........................
7 ........................
8 ........................
9 ........................
10 ......................
11 ......................
12 ......................
13 ......................
14 ......................
15 ......................
16 ......................
17 ......................
18 ......................
19 ......................
20 ......................
496 COPD ......................................................................................................................
331.0 Alzheimer’s Disease .............................................................................................
290.0 Senile Dementia, Uncomp. ..................................................................................
429.9 Heart Disease Unspecified ..................................................................................
436 CVA/Stroke ..............................................................................................................
294.10 Dementia In Other Diseases w/o Behavioral Dist. ............................................
174.9 Breast Cancer ......................................................................................................
153.9 Colon Cancer .......................................................................................................
157.9 Pancreatic Cancer ................................................................................................
332.0 Parkinson’s Disease .............................................................................................
185 Prostate Cancer ......................................................................................................
294.8 Other Persistent Mental Dis.-classified elsewhere ..............................................
585. 6 End Stage Renal Disease ..................................................................................
518.81 Respiratory Failure .............................................................................................
294.11 Dementia In Other Diseases w/Behavioral Dist. ...............................................
188.9 Bladder Cancer ....................................................................................................
Percentage
74,786
64,199
56,234
32,081
31,987
27,417
22,421
22,197
22,007
21,183
21,042
17,762
17,545
12,962
11,751
10,511
6
5
4
2
2
2
2
2
2
2
2
1
1
1
1
1
Source: FY 2002, 2007, and 2012 hospice claims data from the Chronic Conditions Warehouse (CCW), accessed on February 14 and February 20, 2013.
Note(s): The frequencies shown represent beneficiaries that had a least one claim with the specific ICD–9 code reported as the principal diagnosis. Beneficiaries could be represented multiple times in the results if they have multiple claims during that time period with different principal
diagnoses.
III. Summary of the Provisions of the
Proposed Rule
The May 10, 2013 FY 2014 hospice
proposed rule (78 FR 27823) included
the following clarifications, proposals,
and updates:
• Diagnosis reporting on claims;
• Proposed update to the Hospice
Quality Reporting Program;
• FY 2014 Rate Update;
• Update on Hospice Payment Reform
and Data Collection; and
• Technical and Clarifying
Regulations Text Change.
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A. Diagnosis Reporting on Claims
The FY 2014 Hospice Wage Index and
Payment Rate Update proposed rule
clarified appropriate diagnosis reporting
on hospice claims. No proposals were
made regarding diagnosis coding. These
clarifications are not to preclude any
clinical judgment in determining a
beneficiary’s eligibility for hospice
services. Eligibility for hospice services
is based on meeting the eligibility
requirements as stated in § 418.20 of our
regulations: ‘‘an individual must be—
(a) Entitled to Part A of Medicare; and
(b) Certified as being terminally ill in
accordance with § 418.22.’’
1. ICD–9–CM Coding Guidelines
The hospice benefit covers all care for
the terminal illness, related conditions,
and for the management of pain and
symptoms. HIPAA, federal regulations,
and the Medicare hospice claims
processing manual all require that ICD–
9–CM Coding Guidelines be applied to
the coding and reporting of diagnoses
on hospice claims. Regarding diagnosis
reporting on hospice claims, we
clarified in our July 27, 2012 FY 2013
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Hospice Wage Index notice (77 FR
44247 through 44248) that all providers
are required to code and report the
principal diagnosis as well as all
coexisting and additional diagnoses
related to the terminal condition or
related conditions to more fully describe
the Medicare patients they are treating.
2. Use of Nonspecific Symptom
Diagnoses
The proposed rule included
additional diagnosis clarifications to
address current and ongoing diagnosis
reporting patterns noted on hospice
claims, more specifically the use of
nonspecific, symptom diagnoses and
certain dementia diagnoses. In the
proposed rule, we clarified that the
ICD–9–CM codes of ‘‘debility’’ and
‘‘adult failure to thrive’’ listed in the
ICD–9–CM Coding Guidelines under the
classification, ‘‘Symptoms, Signs, and
Ill-defined Conditions’’, are not to be
used as principal diagnoses when a
related definitive diagnosis has been
established or confirmed by the
provider. Therefore, in the proposed
rule, we clarified that ‘‘debility’’ and
‘‘adult failure to thrive’’ should not be
used as principal hospice diagnoses on
the hospice claim form. When reported
as a principal diagnosis, these would be
considered questionable encounters for
hospice care, and the claim would be
returned to the provider for a more
definitive principal diagnosis.
‘‘Debility’’ and ‘‘adult failure to thrive’’
could be reported on the hospice claim
as other, additional, or coexisting
diagnoses. The principal diagnosis
reported should be the condition
determined by the certifying hospice
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physician(s) as the diagnosis most
contributory to the terminal decline.
3. Use of ‘‘Mental, Behavioral and
Neurodevelopmental Disorders’’ ICD–9–
CM Codes
The proposed rule also clarified the
ICD–9–CM Coding Guidelines for
certain dementia codes that are reported
on hospice claims. There are several,
but not all, codes that fall under the
classification, ‘‘Mental, Behavioral and
Neurodevelopmental Disorders,’’ that
encompass multiple dementia diagnoses
that are frequently reported principal
hospice diagnoses on hospice claims,
but are not appropriate principal
diagnoses per ICD–9–CM Coding
Guidelines.
4. Guidance on Coding of Principal and
Other, Additional, and/or Co-Existing
Diagnoses
In the proposed rule, we reiterated
that diagnosis reporting on the hospice
claims should include the appropriate
selection of principal diagnoses as well
as the other, additional and coexisting
diagnoses related to the terminal illness.
In the July 27, 2012 FY 2013 Hospice
Wage Index notice (77 FR 44247), we
provided in-depth information
regarding longstanding, existing ICD–9–
CM Coding Guidelines. We also
discussed related versus unrelated
diagnosis reporting on claims and
clarified that ‘‘all of a patient’s
coexisting or additional diagnoses’’
related to the terminal illness or related
conditions should be reported on the
hospice claim. Based on analysis of
preliminary claims data from the first
quarter of FY 2013 (October 1, 2012
through December 31, 2012), 72 percent
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of providers still only report one
diagnosis on the hospice claim. This
hospice diagnosis data is comparable to
the hospice diagnosis data reported in
the July 27, 2012 FY 2013 Hospice Wage
Index notice (77 FR 44242), in which we
stated that over 77 percent of the
hospice claims reported only a principal
diagnosis.
Information on a patient’s related and
unrelated diagnoses should already be
included as part of the hospice
comprehensive assessment and
appropriate interventions for the
palliation and management of the
terminal illness and related conditions
should be incorporated into the
patient’s plan of care, as determined by
the hospice interdisciplinary group
(IDG).
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5. Transition to ICD–10–CM
The proposed rule reminded the
hospice industry that ICD–10–CM will
replace the ICD–9–CM on October 1,
2014. A critical issue associated with
the transition to ICD–10–CM involves
the matter of crosswalking between the
ICD–9–CM and ICD–10–CM code sets.
The term ‘‘crosswalking’’ is generally
defined as the act of mapping or
translating a code in one code set to a
code or codes in another code set. (The
terms ‘‘crosswalking’’ and ‘‘mapping’’
are sometimes used interchangeably.)
Understanding crosswalking will be
important to physicians during the
transition phase when learning which
new ICD–10 code to use in place of an
ICD–9 code. We provided information
regarding the crosswalks from ICD–9–
CM to ICD–10–CM and this information
is available for free and can be
downloaded from the NCHS Web site,
www.cdc.gov/nchs/icd/icd10cm.htm.
Hospices should not substitute
crosswalking for learning and fully
implementing ICD–10–CM into their
procedures. Additional information
regarding the transition to ICD–10–CM
is available through the CMS Web site
at: https://www.cms.gov/Medicare/
Coding/ICD10/?redirect=/
icd10.
B. Hospice Quality Reporting Program
• We proposed to eliminate two
currently reported measures, the
structural measure related to Quality
Assurance and Performance
Improvement (QAPI) and the NQF
#0209 pain measure, and we offered an
alternate proposal to retain the currently
reported NQF #0209 pain measure until
a suitable comfort outcome measure is
available as described in section III.B.3
of the FY 2014 hospice wage index and
payment update proposed rule (78 FR
27835);
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• We proposed to implement the
Hospice Item Set (HIS), a standardized
patient-level data collection vehicle,
effective 7/1/2014 and to utilize the
seven NQF-endorsed measures derived
from the HIS in the hospice quality
reporting program as described in
section III.B.4 of the FY 2014 hospice
wage index and payment update
proposed rule (78 FR 27836); and
• We proposed that hospices begin
national implementation of the Hospice
Experience of Care Survey by
participating in a dry run in January
2015 through March 2015, and then,
beginning in April 2015, conduct
monthly implementation of the survey
through December 2015 to meet the
requirements of the 2017 annual
payment update as described in section
III.B.6 of the FY 2014 hospice wage
index and payment update proposed
rule (78 FR 27837).
C. FY 2014 Hospice Wage Index and
Rates Update
The proposed updates to the hospice
rates for FY 2014 are as follows:
• Update the hospice wage index
using the 2013 pre-floor, pre-reclassified
hospital wage index as discussed in
section III.C.1 of the FY 2014 hospice
wage index and rate update proposed
rule (78 FR 27839);
• Update the hospice wage index
taking into account the application of
the hospice floor or budget neutrality
adjustment factor reduced an additional
15 percent, for a BNAF phase-out of 70
percent as finalized in the FY 2010
hospice wage index final rule (74 FR
39384), as discussed in section III.C.2 of
the FY 2014 hospice wage index and
rate update proposed rule (78 FR
27840); and
• Apply the hospice payment update
percentage, as discussed in section
III.C.3 of the FY 2014 hospice wage
index and rate update proposed rule, to
the FY 2013 hospice payment rates as
discussed in section III.C.4 of the FY
2014 hospice wage index and rate
update proposed rule (78 FR 27841
through 27842).
D. Update on Hospice Payment Reform
and Data Collection
We did not make any payment reform
proposals or solicit comments on this
section, but included updates and a
discussion of payment reform activities,
including:
• A discussion of reform options,
including the U-shaped curve model, a
tiered model that uses the U-shaped
curve, a short-stay add-on payment, and
case-mix adjustment.
• A discussion of rebasing a portion
of the routine home care (RHC) payment
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48241
rate; adjusting for current costs would
reduce the FY 2014 RHC rate by 10.1
percent.
• A discussion of the Office of
Inspector General (OIG) and MedPAC
recommendations to reduce payments to
hospices for RHC patients in nursing
facilities, to account for duplication of
aide services. The claims visit data on
aide services revealed that hospice
patients in nursing facilities receiving
more visits, but shorter visits than
patients at home; however, on average,
hospice patients in nursing facilities
receive 22 percent more minutes of aide
care than hospice patients at home.
• A discussion of reform research
findings related to cost reports and
general inpatient care (GIP), and a link
to the Abt Hospice Study Technical
Report and an Abt review of the
literature.
• A summary of comments received
from a December, 2012 CMS Web site
posting about additional data collection
on hospice claims; a forthcoming
Change Request will finalize the data
collection this summer.
• An update on the status of the
hospice cost report revisions, which
were published as part of a Paperwork
Reduction Act notice in the Federal
Register on April 29, 2013.
E. Technical and Clarifying Regulations
Text Change
We proposed a technical change to
correct an erroneous cross reference in
our regulations text at § 418.311, as
discussed in section III.E of the FY 2014
Hospice Wage Index and Rate Update
proposed rule (78 FR 27847).
IV. Analysis and Responses to Public
Comments
We received approximately 125
comments, many of which contained
multiple comments, on the FY 2014
hospice wage index and payment rate
update proposed rule. We received
comments from various trade
associations, private insurers,
individual hospices, hospitals,
physicians, medical directors, nurses,
visiting nurses associations, home
health agencies, hospice volunteers, and
individuals. We appreciate the
numerous thoughtful and insightful
comments received and believe that
communication and collaboration
between CMS and all hospice
stakeholders is imperative. The
comments received and our responses to
these comments are grouped by subject
area and are summarized below.
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A. Diagnosis Reporting on Hospice
Claims
We made no new proposals regarding
ICD–9–CM Coding Guidelines in the FY
2014 Hospice Wage Index and Payment
Rate Update proposed rule. However,
we did make clarifications regarding
ICD–9–CM Coding Guidelines for the
selection of principal diagnoses and
additional diagnoses. These
clarifications are not to preclude any
clinical judgment in determining a
beneficiary’s eligibility for hospice
services. Eligibility for hospice services
is based on meeting the eligibility
requirements as stated in § 418.20 of our
regulations: ‘‘. . . an individual must
be—
(a) Entitled to Part A of Medicare; and
(b) Certified as being terminally ill in
accordance with § 418.22.’’
Specifically, we clarified the
following:
• ‘‘Debility’’ or ‘‘adult failure to
thrive’’ should not be used as a
principal hospice diagnosis on the
hospice claim form per ICD–9–CM
Coding Guidelines. ‘‘Debility’’ and/or
‘‘adult failure to thrive’’ may be used as
another, additional, or coexisting
diagnosis on the hospice claim form. If
‘‘debility’’ or ‘‘adult failure to thrive’’ is
reported as the principal diagnosis on
the hospice claim forms, these claims
will be returned to the provider for more
definitive coding.
• Dementia codes classified under
‘‘Mental, Behavioral and
Neurodevelopmental Disorders’’ are
among the top twenty hospice claims
reported diagnoses. Many of these codes
are not appropriate as principal
diagnoses because of manifestation/
etiology guidelines or sequencing
conventions under the ICD–9–CM
Coding Guidelines. Particular attention
must be paid to dementia diagnoses
which are found under two separate
ICD–9–CM classifications: ‘‘Mental,
Behavioral, and Neurodevelopmental
Disorders’’ and ‘‘Diseases of the Nervous
System and Sense Organs.’’ There are
also dementia codes that are classified
under ‘‘Diseases of the Nervous System
and Sense Organs’’ that also have
sequencing conventions and, therefore,
are not appropriate as principal
diagnoses on the hospice claim.
• We provided ICD–9–CM coding
guidance regarding the coding of
principal and other, additional, and/or
coexisting diagnoses. The principal
diagnosis should reflect the condition to
be chiefly responsible for the services
provided. ICD–9–CM Coding Guidelines
specify that the circumstances of an
inpatient hospital admission diagnosis
are to be used in determining the
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selection of a principal diagnosis. ICD–
9–CM Coding Guidelines also state to
‘‘code all documented conditions at the
time of the encounter/visit, and require
or affect patient care treatment or
management.’’ The principal diagnosis
reported on the hospice claim form
should be determined by the hospice as
the diagnosis most contributory to the
terminal prognosis.
• Hospice providers are expected to
report all coexisting or additional
diagnoses related to the terminal illness
and related conditions on the hospice
claim to be in compliance with existing
policy, and provide data needed for
evaluating potential hospice payment
reform methodologies.
• We reminded providers of the
transition to ICD–10–CM, which will
replace ICD–9–CM on October 1, 2014.
• Crosswalking from ICD–9–CM to
ICD–10–CM is important for providers
in understanding the transition between
these two code sets.
We received 109 comments on
diagnosis reporting on hospice claims,
which are summarized below according
to subsection.
1. ICD–9–CM Coding Guidelines
The hospice benefit covers all care for
the terminal illness and related
conditions, including the management
of pain and symptoms. HIPAA, federal
regulations, and the Medicare hospice
claims processing manual all require
that ICD–9–CM Coding Guidelines be
applied to the coding and reporting of
diagnoses on hospice claims. Regarding
diagnosis reporting on hospice claims,
we clarified in our July 27, 2012 FY
2013 Hospice Wage Index notice (77 FR
44247 through 44248) that all providers
should code and report the principal
diagnosis as well as all coexisting and
additional diagnoses related to the
terminal condition or related conditions
to more fully describe the Medicare
patients they are treating.
Comment: Several commenters
expressed concern that the coding
clarification would require that hospices
have a professional coder for coding
claims, which would create a financial
burden on hospice providers. Some
commenters believed that we were
asking hospices to hire professional
coders. Other commenters thought that
we were asking physicians to spend
time determining the proper ICD–9–CM
code for the claim.
Response: We did not state in the FY
2014 hospice wage index and payment
update proposed rule that any hospice
provider would be expected or required
to have a professional coder to complete
the coding on the hospice claims. Our
discussion of the coding guidelines in
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the proposed rule was to assist hospice
providers in complying with
longstanding policies. In our regulations
at 45 CFR 162.1002, the Secretary
adopted the ICD–9–CM code set,
including The Official ICD–9–CM
Guidelines for Coding and Reporting.
The CMS’ Hospice Claims Processing
Manual (Pub 100–04, chapter 11)
requires that hospice claims include
other diagnoses ‘‘as required by ICD–9–
CM Coding Guidelines’’. In the
proposed rule, we provided guidance
from the ICD–9–CM Official Guidelines
for Coding and Reporting to highlight
coding guidelines for principal and
other diagnosis selection, as well as the
various coding and sequencing
conventions found therein. This
clarification of the coding guidelines
was in response to the monitoring of
diagnostic reporting patterns noted on
hospice claims, especially in regards to
the reporting of only one diagnosis and
the use of diagnoses not appropriate as
principal diagnoses per the ICD–9–CM
Coding Guidelines. We believe there are
ample, available resources in regards to
the ICD–9–CM Coding Guidelines to
support hospice providers who choose
not to have a professional coder
complete their hospice claims,
including the links provided within the
proposed rule. These free resources are
available at the following links: https://
www.cms.gov/Medicare/Coding/
ICD9ProviderDiagnosticCodes/
index.html?redirect=/
ICD9ProviderDiagnosticCodes/, https://
www.cms.gov/medicare-coveragedatabase/staticpages/icd-9-codelookup.aspx, or on the CDC’s Web site
at: https://www.cdc.gov/nchs/data/icd9/
icd9cm_guidelines_2011.pdf.
Additionally, more information
regarding guidance for hospice claims
coding can be found in the CMS’
Hospice Claims Processing manual (Pub
100–04, chapter 11) available at https://
www.cms.gov/Regulations-andGuidance/Guidance/Manuals/
Downloads/clm104c11.pdf. Finally,
while hospice physicians use their
clinical judgment to determine the
principal diagnosis and related
conditions, we do not require them to
determine to the actual codes associated
with those diagnoses for inclusion on
the hospice claim. Hospices have the
flexibility to determine how to take the
physicians’ information about diagnoses
and translate it into the appropriate
codes on the claim.
2. Use of Non-Specific, Symptom
Diagnoses
The proposed rule included
additional diagnosis clarifications to
address current and ongoing diagnosis
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reporting patterns noted on hospice
claims, more specifically the use of
nonspecific, symptom diagnoses and
certain dementia diagnoses. In the
proposed rule, we clarified that the
ICD–9–CM codes of ‘‘debility’’ and
‘‘adult failure to thrive’’ are listed in the
ICD–9–CM Coding Guidelines under the
classification, ‘‘Symptoms, Signs, and
Ill-defined Conditions’’, and are not to
be used as principal diagnoses when a
related definitive diagnosis has been
established or confirmed by the
provider. Therefore, in the proposed
rule, we clarified that ‘‘debility’’ and
‘‘adult failure to thrive’’ should not be
used as principal hospice diagnoses on
the hospice claim form. When reported
as a principal diagnosis, these would be
considered questionable encounters for
hospice care, and the claim would be
returned to the provider for a more
definitive principal diagnosis.
‘‘Debility’’ and ‘‘adult failure to thrive’’
could be reported on the hospice claim
as other, additional, or coexisting
diagnoses. The principal diagnosis
reported should be the condition
determined by the certifying hospice
physician(s) as the diagnosis most
contributory to the terminal decline.
Comment: We received numerous
comments in support of or
acknowledging the need for these
diagnostic clarifications and
enforcement of existing coding
guidelines. Several commenters
acknowledged understanding the need
to identify a principal hospice diagnosis
when a patient has multiple diagnoses
instead of using ‘‘debility’’ or ‘‘adult
failure to thrive.’’ Another commenter
stated that their hospice program has
tried to avoid the use of ‘‘debility’’ as a
principal hospice diagnosis and agreed
that this diagnosis has been over-used
nationally; several commenters
acknowledged that there has been
‘‘sloppy diagnosing’’ with the use of
‘‘debility’’ and ‘‘adult failure to thrive.’’
One commenter stated that the use of
‘‘debility’’ or ‘‘adult failure to thrive’’ is
most often a ‘‘failure to diagnose.’’ One
commenter stated that ‘‘debility’’ cannot
be reported as a cause of the death on
a death certificate in his state and that
he had to select a different diagnosis for
an immediate cause of death as well as
a secondary, longer-term related cause.
Several commenters asked what to
expect regarding the application of the
Local Coverage Determination (LCD)
guidelines provided by the Home Health
and Hospice Medicare Administrative
Contractors.
Response: We appreciate that some
hospice providers are recognizing the
issues regarding the inappropriate use of
‘‘debility’’ or ‘‘adult failure to thrive’’ as
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a principal hospice diagnosis reported
on the hospice claim and are attempting
to take steps to more fully describe their
patient populations. We will continue to
work with our Home Health and
Hospice contractors to ensure that all
LCDs will reflect these principal
hospice diagnostic coding clarifications
and that those eligible Medicare hospice
beneficiaries will continue to have
access to the benefits of hospice care.
This collaboration will not be limited to
the release of Change Requests, which
can be found on our hospice Web site
at https://www.cms.gov/Medicare/
Medicare-Fee-for-Service-Payment/
Hospice/Hospice-Transmittals.html.
Additionally, we encourage all
interested stakeholders to participate in
the CMS Home Health and Hospice
Open Door Forums where questions,
concerns and issues can be addressed
with specialists within CMS.
Information regarding Open Door
Forums can be found on our Web site
at https://www.cms.gov/Outreach-andEducation/Outreach/OpenDoorForums/
index.html.
Comment: There were a number of
commenters who expressed concern
that no longer allowing the use of
‘‘debility’’ or ‘‘adult failure to thrive’’ as
a principal hospice diagnosis would
limit or prohibit access to hospice care
for Medicare beneficiaries. Commenters
stated that by not allowing these two
diagnoses to be coded as a principal
hospice diagnosis, they believed that
beneficiaries would elect hospice later
in their disease trajectories. Other
commenters felt that eligible
beneficiaries would not be admitted to
hospice care at all because a single
definitive terminal diagnosis could not
be determined by the certifying
physician. Other commenters stated that
it is difficult to determine a single
principal terminal diagnosis for
beneficiaries with multiple chronic or
coexisting conditions.
Response: Patient-centered care is at
the core of the Medicare hospice benefit.
Our mission is to be effective stewards
of public funds, and we are committed
to strengthening and modernizing the
nation’s health care system to provide
access to high quality care. We believe
that Medicare beneficiaries who are
approaching end-of-life are at their most
vulnerable state and should be afforded
the most comprehensive and
responsible clinical judgment. Medicare
beneficiaries who are hospice eligible
should be fully informed by their health
care providers, including hospice
providers, as to their conditions
contributing to their terminal decline
and their treatment options for ongoing
care. We are aware that diagnosing
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48243
diseases and determining prognosis is
not always a perfect science. Certifying
physicians should use their best clinical
judgment in determining the principal
diagnosis and related conditions, based
on the hospice comprehensive
assessment and review of any and all
other clinical documentation.
It remains our belief that the goal of
hospice care is to provide
comprehensive, holistic, and
individualized services to eligible
Medicare beneficiaries. In order to
receive these comprehensive hospice
services, Medicare beneficiaries must be
certified as terminally ill. This
certification is based on the
recommendation of the medical director
in consultation with, or with input
from, the beneficiary’s attending
physician (if any) and a comprehensive
assessment of all body systems. The
hospice regulations require that this
certification be based on a variety of
factors when making the clinical
determination that a patient has a life
expectancy of 6 months or less, should
the illness run its normal course. The
regulations in § 418.25(b), Admission to
hospice care, state, ‘‘In reaching a
decision to certify that the patient is
terminally ill, the hospice medical
director must consider at least the
following information:
• Diagnosis of the terminal condition
of the patient.
• Other health conditions, whether
related or unrelated to the terminal
condition.
• Current clinical relevant
information supporting all diagnoses.’’
Based on this certification and the
Medicare beneficiary’s election of the
hospice benefit, initial and ongoing
comprehensive assessments are
conducted to establish and maintain the
hospice plan of care. A comprehensive
hospice plan of care starts with accurate
and thorough assessment and
identification of the conditions
(including diseases and symptoms)
contributing to the terminal prognosis.
This comprehensive plan of care is to
include all the services and care needed
for the management and palliation of
the terminal illness and related
conditions. This hospice plan of care is
to include the following, per the
Hospice Conditions of Participation:
• Interventions to manage pain and
symptoms;
• A detailed statement of the scope
and frequency of services necessary to
meet the specific patient and family
needs;
• Measurable outcomes anticipated
from implementing and coordinating
the plan of care;
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• Drugs and treatment necessary to
meet the needs of the patient;
• Medical supplies and appliances to
meet the needs of the patient; and,
• The interdisciplinary group’s
documentation of the patient’s or
representative’s level of understanding,
involvement, and agreement with the
plan of care, in accordance with the
hospice’s own policies, in the clinical
record (§ 418.56(c)).
A hallmark clinical characteristic of
both ‘‘debility’’ and ‘‘adult failure to
thrive’’ is the presence of multiple
primary conditions. According to ICD 9
Coding Guidelines, codes that fall under
the classification ‘‘Symptoms, Signs,
and other Ill-defined Conditions’’, such
as ‘‘debility’’ and ‘‘adult failure to
thrive’’, can only be used as a principal
diagnosis when a related definitive
diagnosis has not been established or
confirmed by the provider. The
individual diagnosed with ‘‘debility’’ or
‘‘adult failure to thrive’’ may have
multiple comorbid conditions that
individually, may not deem the
individual to be terminally ill. However,
the collective presence of these multiple
comorbid conditions will contribute to
the terminal prognosis of the individual.
Additionally, Medicare beneficiaries
waive their right to Medicare payment
for curative treatments under the
Medicare Hospice Benefit; hospice
providers are clinically and ethically
responsible for ensuring that eligible
Medicare beneficiaries are made fully
aware of all of the conditions
contributing to their terminal decline so
they can make the informed decision as
to which treatment approaches they
would like to pursue.
As ‘‘debility’’ and ‘‘adult failure to
thrive’’ are nonspecific, ill-defined,
symptom diagnoses, they should not be
reported as principal diagnosis. Rather,
the condition that the hospice medical
director determines is most contributory
to the terminal prognosis should be
reported as the principal diagnosis on
the hospice claim and all other related
conditions to the terminal prognosis
should be reported as additional
diagnoses. Therefore, the claim should
include not only a principal diagnosis,
but all other related diagnoses as well,
to more fully describe the clinical
picture of the terminally ill individual.
In fact, reporting all of the related
conditions that are contributing to the
terminal prognosis on the hospice claim
may also further support the eligibility
for hospice services. Therefore, we do
not believe that these coding
clarifications will or should create any
limitations or barriers to accessing
Medicare hospice services by eligible
Medicare beneficiaries, as coding on
claims occurs after the beneficiary is
fully informed and has chosen to elect
and access hospice services. In fact,
adherence to the ICD–9–CM Coding
Guidelines should promote access to
appropriate and comprehensive hospice
services. Medicare beneficiaries should
always expect the right care at the right
time and care that best suits their
individual clinical status as well as their
treatment preferences. Further, some
medical experts have argued that these
non-specific, ill-defined terms should be
abandoned because they do not assist in
the thoughtful evaluation of patients
who may have treatable, underlying
conditions.4 We are clarifying these
coding guidelines so that hospice
providers can be more intentional about
addressing all of the beneficiary’s
identified needs as he or she approaches
end-of-life. One physician commenter
stated that he reviews old records, calls
attending physicians, and uses
professional judgment to thoughtfully
evaluate his patients for hospice care.
Analysis conducted by our hospice
payment reform contractor, Abt
Associates, of Medicare hospice
beneficiaries with ‘‘debility’’ or ‘‘adult
failure to thrive’’ reported as their
principal hospice diagnosis, but no
reported secondary diagnoses in FY
2012 revealed that over 50 percent of
these hospice beneficiaries had seven or
more chronic conditions and 75 percent
had four or more chronic conditions as
identified in the Chronic Condition Data
Warehouse. The Chronic Condition Data
Warehouse is a research database that
includes Medicare, Medicaid
assessments and Part D drug event data
to support research designed to improve
the quality of care and reduce cost and
utilization. These chronic conditions
include: Alzheimer’s disease, nonAlzheimer’s dementia, senile
degeneration of the brain, congestive
heart failure, chronic obstructive
pulmonary disease, ischemic heart
disease, chronic kidney disease, and
various cancer diagnoses. While these
conditions are labeled as chronic, many
of these are often terminal conditions as
well, while others are contributory to
the terminal prognosis of the individual.
See Table 3 below:
TABLE 3—CHRONIC CONDITIONS OF THOSE BENEFICIARIES WITH ‘‘DEBILITY’’ OR ‘‘ADULT FAILURE TO THRIVE’’ REPORTED
AS PRINCIPAL HOSPICE DIAGNOSIS BUT WITH NO SECONDARY DIAGNOSES REPORTED, FY 2012
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Percent
Percent
Percent
Percent
Percent
Percent
Percent
Percent
Percent
Percent
Percent
Percent
Percent
Percent
Percent
Percent
Percent
Percent
Percent
Percent
of
of
of
of
of
of
of
of
of
of
of
of
of
of
of
of
of
of
of
Beneficiaries
Beneficiaries
Beneficiaries
Beneficiaries
Beneficiaries
Beneficiaries
Beneficiaries
Beneficiaries
Beneficiaries
Beneficiaries
Beneficiaries
Beneficiaries
Beneficiaries
Beneficiaries
Beneficiaries
Beneficiaries
Beneficiaries
Beneficiaries
Beneficiaries
with
with
with
with
with
with
with
with
with
with
with
with
with
with
with
with
with
with
with
Anemia ............................................................................................................................................
Alzheimer’s Disease and Related Disorders or Senile Dementia .................................................
Rheumatoid Arthritis/Osteoarthritis .................................................................................................
Ischemic Heart Disease .................................................................................................................
Depression ......................................................................................................................................
Heart Failure ...................................................................................................................................
Chronic Kidney Disease .................................................................................................................
Chronic Obstructive Pulmonary Disease and Bronchiectasis ........................................................
Osteoporosis ...................................................................................................................................
Alzheimer’s Disease .......................................................................................................................
Stroke .............................................................................................................................................
Atrial Fibrillation ..............................................................................................................................
Hip/Pelvic Fracture .........................................................................................................................
Asthma ............................................................................................................................................
Acute Myocardial Infarction ............................................................................................................
Breast Cancer .................................................................................................................................
Prostate Cancer ..............................................................................................................................
Colorectal Cancer ...........................................................................................................................
Lung Cancer ...................................................................................................................................
4 Pacala, J.T., Sullivan, G.M. eds. Geriatrics
Review Syllabus: A Core Curriculum in Geriatric
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Medicine. 7th ed. New York: American Geriatrics
Society; 2010.
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66
63
55
53
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39
39
38
34
28
20
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7
5
5
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48245
TABLE 3—CHRONIC CONDITIONS OF THOSE BENEFICIARIES WITH ‘‘DEBILITY’’ OR ‘‘ADULT FAILURE TO THRIVE’’ REPORTED
AS PRINCIPAL HOSPICE DIAGNOSIS BUT WITH NO SECONDARY DIAGNOSES REPORTED, FY 2012—Continued
Percent
Percent of Beneficiaries with Endometrial Cancer ........................................................................................................................
1
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Source: FY 2012 hospice claims data from Chronic Conditions Warehouse (CCW), accessed on June 27, 2013. N = 184,924 hospice beneficiaries with principal diagnosis of ‘‘debility’’ or ‘‘adult failure to thrive’’ with no reported secondary diagnoses on the hospice claim.
Comment: Several commenters stated
that ‘‘Debility’’ is an allowable principal
diagnosis under ICD–9–CM Coding
Guidelines if there is no established or
confirmed definitive diagnosis.
Response: While the ICD–9–CM
Coding Guidelines state ‘‘codes that
describe symptoms, signs, as opposed to
diagnoses, are acceptable for reporting
purposes when a related definitive
diagnosis has not been established
(confirmed) by the provider,’’ we
believe that in encompassing the true
nature of the holistic hospice
philosophy, these ill-defined diagnoses
are not appropriate as the principal
diagnosis on the hospice claim where an
individual has typically had multiple
health care encounters that have
eventually led to their election of
hospice services and physician
certification as being terminally ill. In
the FY 2014 Hospice Wage Index and
Payment Rate Update proposed rule (78
FR 27831), we clarified that if any or all
of these multiple primary conditions (as
characterized under ‘‘debility’’ and
‘‘adult failure to thrive’’) have been or
are being treated, or if medications have
been prescribed for the patient to treat
or manage any or all of these multiple
primary conditions, we believe that
these conditions meet the criteria of
being established and/or confirmed by
the beneficiary’s health care provider
and, thus, ‘‘debility’’ or ‘‘adult failure to
thrive’’ would not be appropriate as the
principal hospice diagnosis per ICD–9–
CM Coding Guidelines. For those
beneficiaries who have not had multiple
health care encounters prior to hospice
election, it is that much more important
that certifying physicians make a
thoughtful evaluation of all of the
conditions contributing to an
individual’s terminal prognosis. The
physician is responsible for making sure
that the individual electing hospice care
is fully aware of all treatment options
available in order for that individual to
make the most informed treatment
decisions.
Comment: Several commenters noted
that hospice eligibility is based on the
prognosis and not the diagnosis, and
some expressed concern as to why CMS
is so focused on the diagnosis.
Response: To address the comments
regarding the focus on diagnosis rather
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than prognosis, eligibility for hospice
services under the Medicare Hospice
Benefit has always been based on the
prognosis of the individual, not
diagnosis, since the implementation of
the Medicare Hospice Benefit in 1983.
As stated in the proposed rule on
August 22, 1983, ‘‘The regulations
would specify, consistent with the
requirements of sections 1812 and
1814(a)(8) of the Act, that to be eligible
for Medicare coverage of hospice care,
an individual must be entitled to
Medicare Part A, and must be certified
as terminally ill’’ (48 FR 38147). These
criteria have not changed, and we
believe that all eligible individuals will
continue to have access to the Medicare
Hospice Benefit. However, certifications
and recertifications of hospice eligibility
are statutory requirements for coverage
and payment. The content of the
certifications and recertifications must
conform to the following requirements
at § 418.22(b), Content of certification.
These requirements include, but are not
limited to the following:
• The certification must specify that
the individual’s prognosis is for a life
expectancy of six months or less if the
terminal illness runs its normal course.
• Clinical information and other
documentation that support the medical
prognosis must be in the medical record
with the written certification.
• The physician must include a brief
narrative explanation of the clinical
findings that supports a life expectancy
of 6 months or less as part of the
certification and recertification forms or
as an addendum to these forms. On
hospice claims however, we are not
seeing the level of completeness of
diagnosis reporting as is required for the
certification and recertifications. As
stated in the proposed rule, data
analysis of preliminary hospice claims
data from the first quarter of FY 2013
(October 1, 2012 through December 31,
2012) showed that over 72 percent of
providers only report one diagnosis on
the hospice claim. Further, analysis of
third quarter FY 2013 data (April 1,
2013 through June 30, 2013 as of July 1,
2013) showed that 69 percent of
providers still only report one diagnosis
on the hospice claim. The hospice
claims processing manual (IOM
Publication #100–04) states that
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principal and other diagnosis codes are
to be reported on the hospice claims
form per ICD–9–CM Coding Guidelines.
Comment: Some commenters felt that
the only reason for the focus on
diagnosis is for CMS to ‘‘save money’’
while shifting costs to the elderly and
that the per diem reimbursement is
being unbundled with these coding
clarifications.
Response: The goal of any
clarification of longstanding, existing
policies such as those relating to ICD–
9–CM Coding Guidelines is to more
fully describe Medicare beneficiaries
who are receiving hospice care. We are
also accountable for maintaining the
integrity and fiscal viability of the
Medicare Trust Funds. Diagnosis
information on claims is also important
as we move forward with hospice
payment reform. Section 3132(a) of the
Affordable Care Act for hospice
payment reform requires that payment
reforms occur no earlier than October 1,
2013, and that the revisions to the
payments implemented result in the
same estimated amount of aggregate
expenditures for hospice care in the
fiscal year that the revisions are
implemented as would have been made
for such care in such fiscal year if such
revisions had not been implemented.
That means any monies saved from any
implemented reform model must go
back into the hospice benefit. The goal
of hospice payment reform is to ensure
appropriate distribution of Medicare
Trust Funds by better aligning payments
with resource use, to pay more
accurately.
However, there has been some
concern, as noted by the Office of the
Inspector General, that some hospices
are not providing the full range of
required hospice services, most notably
drugs, through their per diem
reimbursement to Medicare hospice
beneficiaries (OIG Report A–06–10–
00059, June, 2012). Data analysis
conducted by our hospice payment
reform contractor, Abt Associates,
identified that some hospice-related
drugs for Medicare hospice beneficiaries
are being submitted through Part D
prescription programs instead of being
covered under the Medicare Hospice
Benefit as required by the statute. In
2010, 773,168 Medicare hospice
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received over 334,000 analgesic
prescriptions through Part D during
hospice enrollment totaling
$13,000,430. See Figure (1) below.
This total covered only one drug
class. During 2010, Medicare hospice
beneficiaries received 5,878,425
prescriptions of all classes totaling
$351,750,202. These drug classes
encompassed other hospice-related
drugs including medications for nausea,
shortness of breath, anxiety,
constipation, diarrhea, depression, as
well as disease-specific medications for
the reported principal hospice
diagnosis. We continue to conduct
ongoing analysis regarding the claims
for Medicare hospice beneficiaries to
ensure that hospice providers are
covering the required services, drugs,
supplies, and DME as required by our
regulations at 42 CFR 418.200, 418.202,
and 418.204.
The hospice reimbursement structure
has been a bundled per diem rate since
the implementation of the Medicare
Hospice Benefit. It is not our intent to
‘‘unbundle’’ any of the services required
to be provided by hospices. However, as
shown in the above figure, it is evident
that many drugs used for hospice pain
management are being ‘‘unbundled’’
from the hospice per diem rate, and this
is a concerning trend that we do not
support.
Therefore, we continue to support the
ICD–9–CM Coding Guidelines and stand
by the ICD–9–CM coding clarifications
in the proposed rule. These coding
guidelines are longstanding policies that
we have reiterated in past rules and
notices. No new proposals are being
made; rather we are ensuring that these
existing policies are being adhered to.
As such, ‘‘debility’’ and ‘‘adult failure to
thrive’’ are not allowable as reportable
principal diagnoses on the hospice
claims. However, we recognize that this
may be a paradigm shift for some
hospices in the way they have coded in
the past. Therefore, in recognizing the
process and systems changes that need
to be put in place, claims received with
these codes in the principal diagnosis
field will be returned to the provider for
more definitive coding of the principal
diagnosis and additional diagnoses,
effective for claims dated on or after
October 1, 2014. This will not affect
claims submitted before October 1,
2014. ‘‘Debility’’ and ‘‘adult failure to
thrive’’ may be reported on the hospice
claims as additional diagnoses in the
appropriate claim fields.
Although claims will not be returned
to the provider until the start of FY
2015, we remind hospices that they are
currently, and have always been,
required to code all related diagnoses in
the additional coding fields on the
hospice claim and thus should be doing
so now. We will continue to monitor
and analyze hospice claims data and
may make further clarifications in the
future if necessary. In addition to the
principal diagnosis field, the paper UC–
04 claim form has up to 17 additional
diagnosis fields and the electronic 837I
5010 claim form has up to 24 additional
diagnosis fields allowing for adequate
space for the coding all conditions
related to the beneficiary’s terminal
prognosis.
Comment: Many comments were also
received with specific clinical scenarios
regarding beneficiaries with a reported
hospice diagnosis of ‘‘debility’’ or
‘‘adult failure to thrive.’’ These
comments went on to list these
beneficiaries’ comorbidities including
COPD, atrial fibrillation, congestive
heart failure, and stroke, to name a few.
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these individuals, almost 15 percent
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Other comments included clinical
presentations, rather than specific
diagnoses, and felt that ‘‘debility’’ or
‘‘adult failure to thrive’’ were the only
appropriate diagnoses that could be
assigned. These commenters also report
that they were unable to determine the
principal terminal diagnosis for these
beneficiaries as the individual
conditions did not meet criteria for
being terminally ill per LCDs. Finally,
additional commenters asked about
quantifying comorbidities and whether
Medicare guidelines for eligibility
would be updated to support
comorbidities as terminal diagnoses.
Response: As referenced in our
regulations at § 418.22(b)(1), to be
eligible for Medicare hospice services,
the beneficiary’s attending physician (if
any) and the hospice medical director
must certify that the individual is
terminally ill, that is, the individual’s
prognosis is for a life expectancy of 6
months or less if the terminal illness
runs its normal course as defined in
section 1861(dd)(3)(A) of the Act and set
out at in § 418.22. Therefore, eligibility
under the Medicare Hospice Benefit is
based on the prognosis of the individual
and not only a single diagnosis or
multiple diagnoses. As generally
accepted by the medical community, the
term ‘‘terminal illness’’ refers to an
advanced and progressively
deteriorating illness and the illness is
diagnosed as incurable. When an
individual is terminally ill, many health
problems are brought on by underlying
condition(s), as bodily systems are
interdependent, meaning that there are
multiple conditions, and hence
diagnoses, contributing to the terminal
prognosis. In the proposed rule, we said
that the ICD–9–CM Coding Guidelines,
referring to the selection of the principal
diagnosis, state to list the diagnosis
which is ‘‘chiefly responsible for the
services provided and to list additional
codes that describe any coexisting
conditions.’’ We clarified that the
principal diagnosis listed should be
determined by the certifying hospice
physician(s) as the diagnosis most
contributory to the terminal prognosis.
Furthermore, ICD–9–CM Coding
Guidelines state that when there are two
or more interrelated conditions (such as
diseases in the same ICD–9–CM chapter
or manifestations characteristically
associated with a certain disease)
potentially meeting the definition of
principal diagnosis, either condition
may be sequenced first, unless the
circumstances of the admission, the
therapy provided, the Tabular List, or
the Alphabetic Index indicate
otherwise. In the unusual instance when
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two or more diagnoses equally meet the
criteria for principal diagnosis as
determined by the circumstances of
admission, diagnostic workup and/or
therapy provided, and the Alphabetic
Index, Tabular List, or other coding
guidelines do not provide sequencing
direction, any one of the diagnoses may
be sequenced first. The ICD–9–CM
Coding Guidelines are clear that all
conditions contributing to the need for
services should be listed.
One commenter provided the
following clinical scenario regarding an
individual with a hospice claimsreported principal diagnosis of
‘‘debility:’’
‘‘A patient has dilated cardiomyopathy and
arrhythmia and has a functional
classification of NYHA Class III as he has
symptoms with activity but not at rest. He
also has pulmonary fibrosis causing
shortness of breath with activity. His PPS has
declined to 50 percent in the last 3 months
and he now needs to use a walker and the
assistance for one person ambulating <10 ft.
His weight has declined by 10 percent in the
last six months, and he states that his
appetite has decreased to eating breakfast and
drinking two supplements during the day. He
has been hospitalized two times in the past
year for pneumonia and was hospitalized last
month for arrhythmia requiring medication
adjustments. He does not want further
hospitalizations.’’
In this scenario, there are multiple
conditions listed, including dilated
cardiomyopathy, arrhythmia and
pulmonary fibrosis. Though any of these
conditions, individually, may not deem
the individual as terminally ill, the
progressive nature of these diseases as
well as the collective presence of these
multiple comorbid conditions will
contribute to the terminal prognosis of
the individual. We are clarifying that in
a scenario such as this, the certifying
physician would select the condition he
or she feels is most contributory to the
terminal prognosis, based on
information in the comprehensive
assessment, other relevant clinical
information supporting all diagnoses,
and his or her best clinical judgment.
We are clarifying that this principal
diagnosis, along with the other related
diagnoses, would be included on the
hospice claim. The physician’s clinical
judgment does not negate the fact that
there must be a basis for hospice
certification. A hospice needs to be
certain that the physician’s clinical
judgment can be supported by clinical
information and other documentation
that provide a basis for the certification
of a life expectancy of six months or less
if the illness runs its normal course.
Additionally, the LCDs state that the
terminal illness eligibility guidelines
provided therein are applicable to all
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hospice patients regardless of diagnosis.
The LCD guidelines are intended to be
used to identify any Medicare
beneficiary whose current clinical status
and anticipated progression of disease is
more likely than not to result in a life
expectancy of six months or less. LCDs
are utilized to determine eligibility for
Medicare hospice services and not to
determine the appropriate diagnoses to
code on hospice claims.
The eligibility requirements for
Medicare hospice services were stated
above in a previous response. Eligibility
under the Medicare Hospice Benefit is
based on the prognosis of the individual
and these criteria are not specific to or
limited by any one condition, multiple
conditions or presence of comorbidities.
Rather, the certification of terminal
illness is based in the unique clinical
picture of the individual that is reflected
in the comprehensive assessment and
other clinical records and
documentation that deems the person as
having a life expectancy of six months
or less, should the illness run its normal
course. Therefore, the Medicare Hospice
Benefit eligibility requirements will not
change as a result of the clarifications in
the proposed rule. We believe that the
certifying physicians have the best
clinical experience, competence and
judgment to make the determination
that an individual is terminally ill. We
continue to require the reporting of all
related comorbidities, regardless of the
quantity, in the hospice clinical record
and on the hospice claims.
Comment: We received several
comments regarding whether the
reported principal diagnosis on the
Certificate of Terminal Illness needs to
be changed for current hospice
beneficiaries where ‘‘debility’’ or ‘‘adult
failure to thrive’’ was reported as the
principal terminal condition.
Response: The regulations at
§ 418.22(b) state that that the
certification include—(1) The
certification must specify that the
individual’s prognosis is for a life
expectancy of 6 months or less if the
terminal illness runs its normal course;
(2) 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 as set forth in paragraph
(d)(2) of this section. 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;
(3) The physician must include a brief
narrative explanation of the clinical
findings that supports a life expectancy
of 6 months or less as part of the
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certification and recertification forms, or
as an addendum to the certification and
recertification forms; (4) The physician
or nurse practitioner who performs the
face-to-face encounter with the patient
described in paragraph § 418.22(a)(4)
must attest in writing that he or she had
a face-to-face encounter with the
patient, including the date of that visit.
The attestation of the nurse practitioner
or a non-certifying hospice physician
shall state that the clinical findings of
that visit were provided to the certifying
physician for use in determining
continued eligibility for hospice care;
and (5) All certifications and
recertifications must be signed and
dated by the physician(s), and must
include the benefit period dates to
which the certification or recertification
applies.
Certifications (of which the narrative
is a part) are based on prognosis, not
diagnosis as described above in the
Code of Federal Regulations. Claims
should include a principal diagnosis
and all related diagnoses which form
the prognosis. Certifications are
completed no more than 15 days prior
to the start of the benefit period. A new
certification is not required simply
because a beneficiary’s principal
diagnosis changes nor do benefit
periods or election status change simply
because a principal diagnosis changes.
Comment: We received some
comments expressing concern that no
longer allowing the use of ‘‘debility’’
and ‘‘adult failure to thrive’’ as principal
hospice diagnoses would mean that
Medicare hospice beneficiaries would
be forced into a Medicare ‘‘cookie
cutter’’ mold diagnosis. Several
commenters stated that this would mean
expensive diagnostic testing and/or
hospitalizations to determine the
terminal condition. Some commenters
question what the expectations are for
those people who are just ‘‘dying of old
age’’ and some asked if CMS would
rather see ‘‘otherwise healthy but
elderly patients experience multiple
hospital admissions and nursing home
stays.’’ Another commenter stated that
doctors may feel compelled to ‘‘makeup’’ diagnoses to satisfy this coding
clarification. One commenter asked if
all codes under the classification of
‘‘Symptoms, Signs, and Ill-defined
Conditions’’ are included in these
clarifications.
Response: As stated above, these ICD–
9–CM coding clarifications do not
preclude the clinical judgment of the
certifying physician(s) regarding the
hospice eligibility of any given
Medicare beneficiary; rather, they are to
ensure that all principal and diagnoses
related to the terminal prognosis are
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captured on the Medicare hospice
claims to more accurately describe
hospice beneficiaries receiving the
services, drugs, supplies, and DME
hospices are required to cover under the
regulations at § 418.200, § 418.202, and
§ 418.204. A non-specific, ill-defined
symptom diagnosis such as ‘‘debility’’
and ‘‘adult failure to thrive’’ is more of
a catch-all diagnosis in that a wide
variety of principal and/or comorbid
conditions contribute to these
syndromes. Given the complexity of a
hospice patient, with multiple
conditions often contributing to the
terminal prognosis, we are stating that
all diagnoses contributing to (that is,
related to) the terminal prognosis of the
individual are to be reported on the
hospice claims in order to account for
the individual needs of each and every
Medicare hospice beneficiary.
In evaluating an individual for
hospice eligibility, and especially when
evaluating an individual who has the
clinical characteristics found under
‘‘debility’’ or ‘‘adult failure to thrive’’,
‘‘medical history is probably more
important than physical examination or
laboratory testing as failure to thrive
commonly occurs over the course of
months and common diagnostic testing
has generally been done previously.5 ’’
Therefore, it is our belief that an
individual who has elected hospice care
and has been determined to be
terminally ill by a certifying physician
has more than likely already been
assessed, treated and evaluated by
health care providers, not limited to just
hospice providers, prior to coming to
the decision to elect hospice services
and waive the right to Medicare
payment for other curative services.
Having all related conditions reported
on the hospice claim form, and not just
a single diagnosis, such as an illdefined, symptom diagnosis, will ensure
that hospices are aware of and provide
all of the expert care, including services,
drugs, supplies, and DME, that a
Medicare hospice beneficiary requires
as he or she approaches end-of-life.
In the rare event that no single
definitive terminal diagnosis (or
diagnoses) can be determined by the
certifying physician, whether from lack
of clinical documentation or patient
refusal for diagnostic work-up, then the
expectation would be that all conditions
that are present at the time of hospice
certification that deem the individual as
terminally ill would be reported on the
hospice claim. One example provided
by a commenter is as follows:
5 Verdery, R. (1997). Clinical Evaluation of
Failure to Thrive in Older People. Clinics in
Geriatric Medicine. 13(4), 769–778.
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An 85 year old patient with dysphagia,
decreased oral intake, malnutrition, weight
loss, BMI of 18.6 upon admission, decreasing
functional status, progressed from a walker to
chair to bed in less than six months, but with
no underlying diagnoses. This patient was
determined to be terminally ill by the
certifying physician and this patient was
entered into hospice services.
In this example, while no organ-based
diagnosis could be confirmed by the
certifying physician, the clinical record
reflects that this patient was suffering
from malnutrition, dysphagia, and
decreased functional status and muscle
weakness.
Eligibility for hospice services is not
limited by only disease-specific ICD–9–
CM codes. There are ICD–9–CM codes
for all of the clinical presentations listed
above. This clinical scenario has been
documented in the comprehensive
assessment, and there is a clinical
history of this patient’s decline. CMS’s
expectation is to code these clinical
presentations on the claim as they are
listed in the clinical record. The
condition the physician feels is most
contributory to the terminal prognosis
would be reported first on the hospice
claim form, along with all other related
conditions. There appears to be some
confusion and disconnect from the
comments received regarding the coding
expectations. The rationale for these
clarifications is not to limit or prohibit
access to hospice services, and we
expect hospice providers to render the
hospice care needed for those eligible
individuals. We are only clarifying to
code this level of specificity on the
hospice claim form so we have an
accurate clinical picture of those
Medicare beneficiaries that are receiving
hospice care under their Medicare
Hospice Benefit. This expectation for
specificity in claims coding is found in
every other health care setting for
Medicare beneficiaries—inpatient,
outpatient, home health, skilled nursing
facilities, acute rehabilitation facilities
and in long term care hospitals.
Hospices are expected to follow the
same level of specificity especially
given the complexity of the hospice
patient population.
We recognize that this may be a great
departure from the way some hospice
providers have been accustomed to
coding on hospice claims. Ongoing
analysis of the hospice claims reveals
that a majority of hospices are coding a
single terminal diagnosis. However,
eligibility should always have been
based on the terminal prognosis of the
patient, and this prognosis would
typically involve more than one
diagnosis. Specifically, as stated
previously, analysis of third quarter FY
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2013 data (April 1, 2013 through June
30, 2013 as of July 1, 2013) showed that
69 percent of providers still only report
one diagnosis on the hospice claim.
Prognosis, as many commenters have
noted, is based on a multitude of
clinical processes. We expect hospices
to code these multiple clinical
processes. This may be difficult for
some providers to accept as they may
not understand how malnutrition,
anemia, or depression, for example,
could be reported as a principal hospice
diagnosis. However, many commenters
provided clinical scenarios in which
their patients had one or all of these
clinical presentations that was
contributing to the terminal prognosis of
the individual. We expect hospice
providers to take a holistic approach to
diagnostic coding on the claims form,
reporting the principal diagnosis and all
related diagnoses.
According to § 418.22(b)(3), Content
of certification, ‘‘The physician must
include a brief narrative explanation of
the clinical findings that supports a life
expectancy of six months or less as part
of the certification and recertification
forms; or as an addendum to the
certification and recertification forms.’’
Note that ‘‘clinical findings’’ are
included in the determination of
terminal prognosis, and hospice
eligibility is not limited by or to a single
diagnosis or diagnostic test result(s).
Therefore, expensive diagnostic testing
or hospitalizations are not a requirement
for determining whether an individual
meets Medicare hospice eligibility
criteria if the individual’s clinical
circumstances are evident in that the
conditions present contribute to the
terminal prognosis of the individual.
Oftentimes, if an individual has
reported a past, resolved problem in
their medical history, and that problem
could cause the symptom syndromes of
‘‘debility’’ or ‘‘adult failure to thrive’’,
that problem is the most likely one
underlying the patient’s presentation.6
The expectation remains that hospice
providers, using their best clinical
judgment, knowledge, and expertise,
will ‘‘paint’’ a detailed picture of their
patients to more fully describe Medicare
hospice patients.
If a Medicare beneficiary is reported
to be ‘‘dying of old age’’ or ‘‘otherwise
healthy, but elderly,’’ we believe that
characterization of the beneficiary’s
condition is inconsistent with
classifying the individual as terminally
ill. Eligibility criteria for the Medicare
Hospice Benefit do not include an age
requirement, and advanced age alone is
inadequate documentation of terminal
prognosis.
It is normal clinical practice for health
care providers to fully inform their
patients about their health status. An
eligible beneficiary who is considering
hospice, and who has not seen a doctor
in years, should be fully informed by
the potential hospice provider about the
conditions contributing to their terminal
prognosis and their palliative treatment
options for ongoing care.
Often, many other treatable health
conditions could be contributing to the
clinical characteristics associated with
‘‘debility’’ and ‘‘adult failure to
thrive.’’ 7 These conditions may include:
Alzheimer’s Disease, depression,
primary anorexia, diabetes, cancer,
chronic lung disease, stroke, chronic
urinary tract infections, chronic steroid
use, medication reactions, just to name
a few. Any eligible individual (or
representative) who is electing hospice
under the Medicare Hospice Benefit
must acknowledge that he or she has
been given a full understanding of the
palliative rather than the curative nature
of hospice care, as it relates to the
individual’s terminal illness
(§ 418.24(b)(2)). Upon electing the
Medicare hospice benefit, an eligible
patient acknowledges his/her
understanding that Medicare will no
longer pay for curative treatment for the
terminal illness and related conditions,
and thus the patient is essentially
waiving curative treatment under
Medicare, and instead elects to receive
palliative care to manage pain or
symptoms. It is the hospice provider’s
responsibility to ensure that the
individual is fully informed and
acknowledges understanding that he or
she is essentially waiving curative
treatment and electing only palliative
care, so the individual (or
representative) can make his or her own
informed decision.
The expectation remains that all
conditions (hence, diagnoses) that are
contributing to (that is, related to) the
terminal prognosis of the individual
would be reported on the hospice
claims to fully represent the
individual’s clinical status and the
hospice interventions that are being
provided to address the individual’s
needs.
We do not endorse ‘‘making up’’ a
diagnosis in order for hospice claims
submission. We believe that
beneficiaries’ physicians are in the best
clinical position to determine those
6 Verdery, R. (1997). Clinical Evaluation of
Failure to Thrive in Older People. Clinics in
Geriatric Medicine. 13(4), 769–778.
7 Verdery, R. (1997). Clinical Evaluation of
Failure to Thrive in Older People. Clinics in
Geriatric Medicine. 13 (4), 769–778.
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conditions that are contributing to the
terminal prognosis of their patients. We
expect that they will use responsible
decision making to determine the
diagnosis contributing most to the
terminal prognosis utilizing the
information from the clinical records
and the comprehensive assessments.
While the ICD–9–CM Coding Guidelines
for ‘‘Symptoms, Signs and Ill-defined
Conditions’’ do apply for all codes
under this ICD–9–CM classification, we
are currently focusing on the two most
frequently reported hospice claims
diagnoses from this classification,
‘‘debility’’ and ‘‘adult failure to thrive.’’
However, we will continue to monitor
the diagnostic coding patterns on
hospice claims for any further issues or
clarifications that may be needed in this
regard.
Comment: A few commenters
suggested, for those cases reported with
‘‘debility’’ or ‘‘adult failure to thrive’’ as
the principal diagnosis, there should be
a mandatory medical review rather than
these patients not receiving hospice care
or to only ‘‘punish’’ those that have
abused ‘‘debility.’’ One commenter
suggested that CMS limit the number of
patients per hospice with ‘‘debility’’ and
‘‘adult failure to thrive’’ with a 3 percent
cap.
Response: As noted previously,
‘‘debility’’ and ‘‘failure to thrive’’
comprised 20 percent of the Medicare
hospice population in FY 2012. This is
a substantial number of individuals that
hospice providers are saying have no
other diagnoses or conditions that could
be determined or confirmed.
Conducting mandatory medical reviews
on each and every one of these cases
would require substantial
administrative burden and costs. Rather,
we are not stating that individuals with
the clinical manifestations of ‘‘debility’’
and ‘‘adult failure to thrive’’ are
ineligible for hospice services under the
Medicare Hospice Benefit. Eligibility is
determined by the certifying physician
and based on the review of the clinical
records and comprehensive assessment.
These clarifications are to ensure that
hospice providers are fully describing
their Medicare hospice patients, which
should assist them in fully
understanding and treating all of the
conditions contributing to the terminal
prognosis and not just a single terminal
diagnosis.
It is our belief that hospice providers
would not support having another cap
requirement regarding their census
populations. We recognize there are
many new and ongoing requirements
that hospice providers must fulfill in
addition to providing high-quality, endof-life care for Medicare beneficiaries.
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Therefore, it is not our intent, at this
time, to implement any new cap
requirements or ‘‘punishments’’ on
hospice providers with these coding
clarifications. We expect that hospice
providers will continue to assess and
evaluate their own organizational
policies and processes to ensure that
they are able to meet requirements and
to continue to meet the needs of their
patients.
Comment: One commenter stated,
‘‘The need to document secondary
diagnoses is recognized. It was actually
commonly done in the pre-electronic
record (EMR) days, but got lost by many
hospices with limitations in software
systems’’. One commenter stated that
barriers existed with electronic medical
record systems that did not allow
additional diagnoses to flow to the
claim. These commenters went on to say
that many of these barriers have been
removed and that the majority of
hospice providers are either now in
compliance with the requirement to
include multiple diagnoses or are in the
process of implementing procedures
and technology in order to be in
compliance. One commenter stated that
their hospice software vendor has not
developed a process to allow for
inclusion of related diagnoses on their
claims forms. This commenter went on
further to say that it would be an
obstacle for hospice providers to make
software changes to comply with the
ICD–9–CM coding clarifications
regarding the reporting of related
diagnoses. Several commenters stated
that the occurrence of reporting a
principal diagnosis of ‘‘debility’’ or
‘‘adult failure to thrive’’ is uncommon.
Response: We appreciate the
comment regarding the common
hospice practice of including secondary
diagnoses in the past. While we
understand that software systems may
pose some obstacles in reporting more
than one diagnosis on the hospice
claim, we also believe that this practice
of reporting the conditions contributing
to (that is, related to) the terminal
prognosis is one that has been
communicated since the
implementation of the hospice benefit.
The expectation is for this practice to
continue and for hospice providers to be
active in ensuring that their processes
and systems promote the hospice
philosophy of holistic, comprehensive
care and the intent of the Medicare
Hospice Benefit in supporting that
access for the Medicare population.
As mentioned in the proposed rule,
there are hospice providers who are
reporting more than just the principal
diagnosis, so it appears that there are
electronic systems currently in place
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that allow for the inclusion of multiple
diagnoses. However, data analysis of
hospice claims continues to show that
the majority of hospice providers (69
percent of hospice providers, as stated
in previous responses) continue to
report only one diagnosis on hospice
claims. Additionally, software systems
are typically designed with end user
input so we believe those software
systems that only allow one diagnosis
were because those hospices
communicated to the software vendors
that their needs for claims coding were
to include only one diagnosis. We
expect hospices to articulate to the
vendors the requirements of the
software that complies with our
requirements. Furthermore, we have
reiterated in past notices and rules
regarding our expectation of the
inclusion of the principal hospice
diagnosis as well as all related
conditions. As mentioned previously, in
addition to the principal diagnosis field,
the paper UC–04 claim form has up to
17 additional diagnosis fields, and the
electronic 837I 5010 claim form has up
to 24 additional diagnosis fields
allowing for adequate space for the
coding all conditions contributing to
(that is, related to) the beneficiary’s
terminal condition. Therefore, we
believe that we have provided ample
notice and time for hospice providers to
evaluate their claims software systems
to make the necessary systems
adjustments for the inclusion of all
related diagnoses. However, we also
recognize that this will require some
software systems adjustments for several
hospice providers, and we are sensitive
to those time requirement needs. To
address the comments regarding the rare
occurrences of the use of ‘‘debility’’ or
‘‘adult failure to thrive’’ as a principal
diagnosis, a review of 2011 and 2012
data from the Chronic Condition
Warehouse revealed the following
information (See Table 4 and Table 5):
TABLE 4—PERCENTAGE OF HOSPICE
PROVIDERS EVER REPORTING ‘‘DEBILITY’’ OR ‘‘ADULT FAILURE TO
THRIVE’’ AS THE PRINCIPAL HOSPICE
DIAGNOSIS WITH NO REPORTED
SECONDARY DIAGNOSES
Condition
Debility ......................
Adult Failure to
Thrive ....................
FY 2011
%
FY 2012
%
89.3
88.9
87.3
87.6
Source: FY 2011 and FY 2012 Claims from
Chronic Conditions Warehouse (CCW).
Accessed on 7/19/13.
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TABLE 5—PERCENTAGE OF CLAIMS
WITH ‘‘DEBILITY’’ OR ‘‘ADULT FAILURE TO THRIVE’’ AS REPORTED
PRINCIPAL DIAGNOSIS WITH NO REPORTED SECONDARY DIAGNOSES
Condition
Debility ......................
Adult Failure to
Thrive ....................
FY 2011
(%)
FY 2012
(%)
11.96
12.07
7.55
7.83
Source: FY 2011 and FY 2012 Claims data
from Chronic Conditions Warehouse (CCW).
Accessed on 7/19/13.
This data indicates that the majority
of hospice providers are reporting
‘‘debility’’ and ‘‘adult failure to thrive’’
as a principal hospice diagnosis, thus
this is not a rare occurrence as
commenters have stated. Additionally,
claims with ‘‘debility’’ or ‘‘adult failure
to thrive’’ as the reported principal
hospice diagnosis accounted for almost
20 percent of total hospice claims for
both FY 2011 and FY 2012.
Comment: We received several
comments regarding hospice claims
with a principal diagnosis of ‘‘debility’’
or ‘‘adult failure to thrive’’ being
returned to the provider immediately for
more definitive coding. Some expressed
that CMS is ‘‘jumping the gun’’ by
announcing that claims would be
returned to the provider before the
comment period is over and were
concerned that claims would starting
returning upon publication of the
proposed rule. Several commenters
expressed concern regarding the ‘‘denial
of claims payment’’ for claims received
with ‘‘debility’’ or ‘‘adult failure to
thrive’’ reported as the principal
diagnosis.
Response: We apologize for any
confusion that may have resulted from
our statement in the FY 2014 Hospice
Wage Index and Payment Rate Update
proposed rule regarding claims being
returned to providers for more definitive
coding. We stated in the proposed rule:
‘‘. . . we would clarify that ‘‘debility’’
and ‘‘adult failure to thrive’’ would not
be used as principal diagnoses of the
hospice claim form. When reported as a
principal diagnosis, these would be
considered questionable encounters for
hospice care, and the claims would be
returned to the provider, not denied, for
a more definitive principal diagnosis.’’
We did not specify any time frame for
these claims or the effective date of
implementation. The intent was not to
immediately return claims to the
provider upon publication of the
proposed rule, and the returned claim is
not a denial of the claim, but a request
for a more definitive and appropriate
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principal diagnosis. ‘‘Debility’’ and
‘‘adult failure to thrive’’ could be
reported on the hospice claim as other,
additional, or coexisting diagnoses. We
understand that this is a shift from the
way some hospice providers have coded
in the past and that there needs to be
adequate time to ensure that all clinical
and electronic processes are in place
and functioning as not to create
unnecessary administrative burden in
an accelerated time frame.
Comment: There were several
comments questioning what is
considered related or unrelated to the
terminal condition. One commenter
stated that it is difficult to determine if
a diagnosis is related to the terminal
condition with an example given stating
that renal failure may or may not be
related to congestive heart failure.
Another commenter, a hospice
physician, provided a clinical scenario
for a beneficiary with chronic
obstructive pulmonary disease (COPD)
as the principal diagnosis, but who also
had coronary artery disease (CAD) and
Parkinson’s disease which the hospice
considered unrelated comorbid
conditions. The patient would only
receive hospice services for care related
to the lung disease (COPD). Another
commenter expressed concern that
including all of the related diagnoses on
the hospice claim would mean that
hospices would have additional costs
incurred in covering all of the
medications for the reported diagnoses.
Response: It is our goal to maintain
the integrity of hospice philosophy and
the Medicare Hospice Benefit. The
intent of the Medicare Hospice Benefit
is to provide all-inclusive care for pain
relief and symptom management for the
terminal prognosis and related
conditions, and offer the opportunity to
die with dignity in the comfort of one’s
home rather than in an institutional
setting. It is often not a single diagnosis
that represents the terminal prognosis of
the patient, but the combined effect of
several conditions that makes the
patient’s prognosis terminal. In
§ 418.54(c), the hospice Conditions of
Participation stipulate that the
comprehensive hospice assessment
must identify the patient’s physical,
psychosocial, emotional, and spiritual
needs related to the terminal illness and
related conditions which must be
addressed in order to promote the
hospice patient’s well-being, comfort,
and dignity throughout the dying
process. The comprehensive assessment
must take into consideration the
following factors: The nature and
condition causing admission (including
the presence or lack of objective data
and subjective complaints);
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complications and risk factors that affect
care planning; functional status;
imminence of death; and severity of
symptoms (§ 418.54(c)). The Medicare
Hospice Benefit requires the hospice to
cover all palliative care related to the
terminal illness and related conditions.
The hospice plan of care is established
based on the review of the clinical
records and the comprehensive hospice
assessments in order to ensure that all
care needs at the end-of-life are
addressed. Section 1861(dd)(1) of the
Act establishes the services that are to
be rendered by a Medicare certified
hospice program. These covered
services include: Nursing care; physical
therapy; occupational therapy; speechlanguage pathology therapy; medical
social services; home health aide
services (now called hospice aide
services); physician services;
homemaker services; medical supplies
(including drugs and biologics); medical
appliances; counseling services
(including dietary counseling); shortterm inpatient care (including both
respite care and procedures necessary
for pain control and acute or chronic
symptom management) in a hospital,
nursing facility, or hospice inpatient
facility; continuous home care during
periods of crisis and only as necessary
to maintain the terminally ill individual
at home; and any other item or service
which is specified in the plan of care
and for which payment may otherwise
be made under Medicare, in accordance
with Title XVIII of the Act.
We recognize that there are conditions
that are unrelated to the terminal
condition of the individual. This is why
there are the ongoing assessment
requirements of the hospice
beneficiaries and the collaboration with
the hospice IDG—to ensure that the
ongoing and changing needs of the
hospice beneficiary are assessed and
changes to the plan of care are made.
However, in referring to the holistic
intent of hospice philosophy and care,
we wrote in the August 22, 1983
proposed rule, ‘‘. . . we recognize that
there are many illnesses which may
occur when an individual is terminally
ill which are brought on by the
underlying condition of the patient’’ (48
FR 38147). In reviewing the many
clinical scenarios provided by
commenters and their interpretations of
what they consider related versus
unrelated, it is apparent that the
majority refer to a ‘‘related condition’’ as
one that is related only to the reported
single, principal terminal diagnosis and
not to the terminal prognosis. However,
within those same comments, it was
stated numerous times that hospice
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eligibility is related to the prognosis of
the individual. One example provided
from a hospice physician regarding a
Medicare hospice beneficiary who had a
reported principal terminal diagnosis of
chronic obstructive pulmonary disease
(COPD). This individual also had
documented coronary artery disease
(CAD) and Parkinson’s disease. The
provider stated that the CAD and the
Parkinson’s disease are unrelated to the
COPD and that the patient would only
receive hospice services for the COPD.
This scenario and accompanying
statement does not appear to encompass
hospice philosophy of holistic care.
Therefore, we are restating what we
communicated in the December 16,
1983 Hospice final rule regarding what
is related versus unrelated to the
terminal illness: ‘‘. . . [W]e believe that
the unique physical condition of each
terminally ill individual makes it
necessary for these decisions to be made
on a case-by-case basis. As stated in the
December 16, 1983 Hospice final rule,
. . . ‘‘hospices are required to provide
virtually all the care that is needed by
terminally ill patients.’’ (48 FR 56010).
Therefore, unless there is clear evidence
that a condition is unrelated to the
terminal prognosis, all services would
be considered related. It is also the
responsibility of the hospice physician
to document why a patient’s medical
need(s) would be unrelated to the
terminal prognosis. We continue to
reiterate that this determination of what
is related versus unrelated to the
terminal prognosis remains within the
clinical expertise and judgment of the
hospice medical director in
collaboration with the IDG.
Comment: Two commenters stated
that the reference to the 1983 final rule
preamble language quoted above, is
casting aside language found in the
§ 418.402, ‘‘Individual liability for
services that are not covered hospice
care’’. These comments went on to say
that § 418.402 ‘‘identified items as
unrelated and not the responsibility of
the hospice for ‘services received for the
treatment of an illness or injury not
related to the individual’s terminal
condition’.’’
Response: The referenced § 418.402,
‘‘Individual liability for services that are
not considered hospice care’’ states,
‘‘Medicare payment to the hospice
discharges an individual’s liability for
payment for all services, other than the
hospice coinsurance amounts described
in § 418.400. . .’’ This section goes on
to state what payment liabilities a
hospice beneficiary would be
responsible for (not the hospice
provider per the commenters) including
‘‘. . . Medicare deductibles and
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coinsurance payments and for the
difference between the reasonable and
actual charge on unassigned claims on
other covered services that are not
considered hospice care.’’ Examples of
non-hospice services are provided in
this section including ‘‘. . . Medicare
services received for the treatment of an
illness or injury not related to the
individual’s terminal condition.’’ We
have previously acknowledged that
there are those rare circumstances in
which a service may not be related to
the patient’s terminal prognosis and that
this determination is to be done on a
case-by-case basis by the hospice
physician with input from the IDG.
However, § 418.402 refers to the liability
limitations for the hospice beneficiary
and does not refer to the liability to the
hospice provider. To infer that this
section is a confirmation of the liability
limitations to the hospice provider
would be incorrect.
Comment: Several commenters stated
that the hospice physician, along with
input from the IDG, have a process in
place to help determine related versus
unrelated conditions and results in the
holistic and comprehensive care their
patients need. Other commenters
explained that the software system
utilized by their hospice agency marks
conditions either as ‘‘active’’ (meaning,
related) or ‘‘historical’’ (meaning,
unrelated). If a condition went from a
historical state to an active state during
the course of a hospice episode, then
that condition was then considered
related and treated accordingly under
the hospice plan of care. Another
commenter said that while some
conditions are unrelated to the terminal
condition, the clinical manifestations of
these unrelated conditions are as such
that they contribute to the individual’s
symptom burden, and the hospice
provider still provides symptom
management for these seemingly
unrelated conditions to meet the
patient’s needs.
Response: We applaud these hospices
in providing a patient-centered
approach and embracing the holistic
hospice philosophy. These are all
examples of hospice providers coming
up with innovative ways to manage the
needs of the hospice beneficiaries.
These are reflections of the true intent
of hospice philosophy that have been
incorporated into the Medicare Hospice
Benefit. We encourage all hospice
providers to assess their operational
processes and clinical and claims
systems to be innovative in meeting the
challenges of providing end-of-life care
for the Medicare hospice beneficiaries
as health care, in general, transitions to
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accountability and value-based models
of care.
Comment: One commenter stated that
these diagnostic clarifications are a
change in coverage policy and CMS
must use a National Coverage Decision
process to change coverage policy rather
than through the preamble discussion of
the proposed rule.
Response: We continue to state that
these coding clarifications are for
hospice claims reporting only and are
not a question of hospice eligibility or
access to coverage. Eligibility to access
the Medicare Hospice Benefit remains
the same since the implementation of
the benefit in 1983. To restate, eligibility
for the Medicare Hospice Benefit is
based on the individual being entitled to
Part A of Medicare and being certified
as terminally ill in accordance with
§ 418.22. These eligibility requirements
for coverage have not changed and are
not changing in this rule. We expect
hospice providers will not discharge,
from hospice services, those
beneficiaries who meet eligibility
requirements but for whom they cannot
determine a single, principal hospice
diagnosis. If a Medicare beneficiary
meets the eligibility requirements as
stated in § 418.20 and as referenced
above, that Medicare beneficiary will
have access to hospice services under
the Medicare Hospice Benefit. The
intent of these coding clarifications is to
request more clarity and detail on the
hospice claims to reflect a complete
picture of the Medicare hospice
population and the hospice services
rendered and not to make any changes
in coverage or eligibility policies.
Therefore, we reject the comment that
CMS must use the National Coverage
Decision process.
Comment: We received a few
suggestions to help further clarification
regarding diagnostic coding in the
hospice setting. One commenter
suggested that CMS work with the
National Hospice and Palliative Care
Organization (NHPCO) to develop
guidelines regarding diagnostic coding
for hospices. Another commenter
suggested that CMS needs to guide
standardization of the hospice industry.
The American Academy of Hospice and
Palliative Medicine (AAHPM) suggested
collaboration with CMS to convene a
Palliative Medicine and Hospice Coding
and Documentation Learning Network
to have ongoing dialogue regarding
coding issues and suggestions for the
hospice industry.
Response: We appreciate the
numerous thoughtful and insightful
suggestions that have been provided in
response to the diagnostic clarifications.
CMS strives to involve all stakeholders
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in the collaborative process as health
care navigates through the 21st century
and health care reform provisions. We
continue to have ongoing discussions
with the industry, including the
national hospice organizations, to
remain aware of the issues that affect
the hospice providers and impact
Medicare beneficiaries. We believe that
this communication and collaboration
will reflect in our ongoing advocacy for
the Medicare hospice beneficiaries to
ensure accountability, responsibility
and quality end-of-life care. We will
continue to provide outcomes of these
communications via Medicare Learning
Network (MLN) articles and through our
Open Door Forums to ensure that all
Medicare stakeholders are kept
informed of progress in maintaining the
integrity of the Medicare Hospice
Benefit.
Final Decision: We will require these
coding changes beginning on October 1,
2014. On or after October 1, 2014, any
claims with ‘‘debility’’ or ‘‘adult failure
to thrive’’ in the principal diagnosis
field will be returned to the provider for
more definitive principal diagnosis
coding. Claims submitted prior to
October 1, 2014 with ‘‘debility’’ or
‘‘adult failure to thrive’’ in the principle
diagnosis field on the claim will not be
returned to the provider, but we expect
that hospice providers will code the
principal hospice diagnosis according to
the ICD–9–CM Coding Guidelines and
the clarifications made herein. This
should provide more than ample time
for hospice providers to meet with
clinical staff and their software vendors
to ensure that these coding needs are
addressed and processes put into place
to ensure continuity of care and
systems. These returned claims, based
on the principal diagnoses of ‘‘debility’’
or ‘‘adult failure to thrive,’’ are not a
denial of payment because of
questionable eligibility; rather, these
claims are being returned for additional
clarity. Once resubmitted with
diagnostic codes following the ICD–10–
CM Coding Guidelines, these claims will
be processed and paid accordingly.
However, we expect hospice providers
to transition immediately to more
thoughtful coding practices in advance
of this effective date.
3. Use of ‘‘Mental, Behavioral and
Neurodevelopmental Disorders’’ ICD–9–
CM Codes
In the proposed rule we discussed the
use of hospice claims-reported principal
hospice diagnoses that fall under the
ICD–9–CM classification, ‘‘Mental,
Behavioral and Neurodevelopmental
Disorders.’’ There are several codes that
fall under this classification that
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encompass multiple dementia diagnoses
that are frequently reported principal
hospice diagnoses on hospice claims,
but are not appropriate principal
diagnoses per ICD–9–CM Coding
Guidelines. There are, however, other
ICD–9–CM dementia codes, such as
those for Alzheimer’s disease and
others, that fall under the ICD–9–CM
classification, ‘‘Diseases of the Nervous
System and Sense Organs’’ which are
acceptable as principal diagnoses per
ICD–9–CM coding guidelines.
Comment: One commenter expressed
concern that ‘‘Lewy Body Dementia,’’
‘‘Fronto-temporal Dementia’’ and
‘‘Vascular Dementia’’ are no longer
allowed as principal hospice diagnoses.
Another commenter questioned what
would be the recommendation if the
hospice provider is unable to determine
the cause of the dementia either from a
lack of medical records or specific
diagnostic work-up. One commenter
asked if the LCD for ‘‘Alzheimer’s
Disease and Related Disorders’’ would
be applicable to use for coding
guidance.
Response: In the FY 2014 Hospice
wage index and payment rate update
proposed rule (78 FR 27823), we did not
state the specific dementia conditions
and their corresponding ICD–9–CM
codes that fall under various coding and
sequencing conventions in the ICD–9–
CM Coding Guidelines. There are many
codes for dementia conditions,
including the neurological causes as
well as the clinical mental and
behavioral manifestations of the
underlying condition. These dementia
conditions and ICD–9–CM codes are too
numerous to list within the context of
the proposed and final rules but are
found in the ICD–9–CM Official
Guidelines for Coding and Reporting
manual. However, we clarified that
dementia codes can be found under two
classifications in the ICD–9–CM Official
Guidelines for Coding and Reporting,
‘‘Mental, Behavioral and
Neurodevelopmental Disorders’’ and
‘‘Diseases of the Nervous System and
Sense Organs.’’ Per ICD–9–CM Coding
Guidelines, several, but not all, of these
ICD–9–CM dementia codes are
considered manifestation codes,
especially those dementia codes
classified under ‘‘Mental, Behavioral
and Neurodevelopmental Disorders’’. In
accordance with the 2012 ICD–9–CM
Coding Guidelines, ‘‘certain conditions
have both an underlying etiology and
multiple body system manifestations
due to the underlying etiology. For such
conditions, the ICD–9–CM has a coding
convention that requires the underlying
condition be sequenced first followed
by the manifestation. Wherever such a
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combination exists, there is a ‘‘use
additional code’’ note at the etiology
code, and a ‘‘code first’’ note at the
manifestation code. These instructional
notes indicate the proper sequencing
order of the codes, etiology followed by
manifestation.’’ In most cases, these
manifestation codes will have in the
code title, ‘‘in diseases classified
elsewhere’’ or ‘‘in conditions classified
elsewhere.’’ Codes with this in the title
are a component of the etiology/
manifestation convention. The codes
with the phrase ‘‘in diseases classified
elsewhere’’ or ‘‘in conditions classified
elsewhere’’ in the title indicate that they
are manifestation codes. ‘‘In diseases
classified elsewhere’’ or ‘‘in conditions
classified elsewhere’’ codes are never
permitted to be used as first listed or
principal diagnosis codes and they must
be listed following the underlying
condition. However, there are
manifestation codes that do not have ‘‘in
diseases classified elsewhere’’ or ‘‘in
conditions classified elsewhere’’ in their
title. For such codes a ‘‘use additional
code’’ note would still be present, and
the rules for coding sequencing still
apply. We noted that several dementia
codes which are not allowable as
principal diagnoses per ICD–9–CM
coding guidelines are under the
classification of ‘‘Mental, Behavioral
and Neurodevelopmental Disorders.’’
According to the ICD–9–CM Coding
Guidelines for ‘‘Mental, Behavioral and
Neurodevelopmental Disorders’’,
dementias that fall under this category
are ‘‘most commonly a secondary
manifestation of an underlying causal
condition.’’
Two of the most frequently reported
dementia codes on hospice claims fall
under this manifestation/etiology
convention: ‘‘dementia in conditions
classified elsewhere with behavioral
disturbance’’ and ‘‘dementia in
conditions classified elsewhere without
behavioral disturbance’’. Per ICD–9–CM
Coding Guidelines, these codes are not
acceptable as a reported principal
diagnosis, and the underlying physical
condition must be coded first. These
codes can be used as additional or other
diagnoses on the hospice claim.
Additionally, two other frequently
reported dementia codes on hospice
claims have underlying disease-specific
sequencing conventions: ‘‘senile
dementia, uncomplicated’’ and ‘‘other
persistent mental disorders due to
conditions classified elsewhere’’. There
are ICD–9–CM Coding Guidelines
specific to each of these codes and these
codes cannot be used as the principal
diagnosis but can be reported as
additional or other diagnoses on the
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hospice claim. Instructional notes
regarding the sequencing convention for
each of these codes can be found under
each of these codes in the Tabular List
within the ICD–9–CM Official
Guidelines for Coding and Reporting.
Therefore, it is imperative that hospice
providers understand and follow ICD–
9–CM Coding Guidelines and
sequencing rules for all diagnoses and
especially those noted above. We
encourage hospice providers to pay
particular attention to dementia coding
as there are dementia codes found in
more than one ICD–9–CM classification
chapter, and there are multiple coding
guidelines associated with these
dementia conditions.
The clarification of these coding
guidelines is not to determine eligibility
for hospice services, but rather, these
guidelines are to assist with the proper
coding sequences for the hospice
claims. Eligibility for Medicare hospice
services continues to be based on the
prognosis of the individual based on the
clinical judgment of the certifying
physician that the individual has a life
expectancy of 6 months or less if the
terminal condition runs its normal
course. CMS does not make any
recommendations as to what specific
diagnoses to select from the ICD–9–CM
Official Guidelines for Coding and
Reporting for an individual beneficiary
as these selections are to be determined
by the certifying physician(s) based on
the clinical record review and the
comprehensive assessment. There are
dementia diagnoses, including
Alzheimer’s Disease, Lewy-Body
Dementia, fronto-temporal dementia,
and senile degeneration of the brain, to
name a few, that are allowable as
principal diagnoses per ICD–9–CM
Coding Guidelines and are located
under the classification of ‘‘Diseases of
the Nervous System and Sense Organs’’
in the ICD–9–CM Official Guidelines for
Coding and Reporting manual.
Some of the ICD–9–CM dementia
diagnoses take into account that some
dementia conditions may be unspecified
in the event that a definitive diagnostic
work-up was not or could not be
performed. However, based on the
present and historical clinical
presentation of the individual, there are
unspecified dementia diagnoses and
corresponding ICD–9–CM codes that are
acceptable as a principal diagnosis per
ICD–9–CM Coding Guidelines. Most of
these codes can be found under the
classification, ‘‘Diseases of the Nervous
System and Sense Organs.’’ However,
the expectation remains that the
certifying physician will select the
appropriate diagnoses and codes that
determine the terminal prognosis of the
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individual and that are most
contributory to the terminal decline.
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4. Guidance on Coding of Principal and
Other, Additional, and/or Co-existing
Diagnoses
In the FY 2014 Hospice Wage Index
and Payment Rate Update proposed
rule, we stated based on the ICD–9–CM
Coding Guidelines, that the
circumstances of an inpatient admission
always govern the selection of principal
diagnosis (78 FR 27833). The principal
diagnosis is defined in the Uniform
Hospital Discharge Data Set (UHDDS) as
‘‘that condition established after study
to be chiefly responsible for occasioning
the admission of the patient to the
hospital for care.’’ In analyzing
frequently reported principal hospice
diagnoses, data analysis revealed
differences between reported principal
hospice diagnoses and reported
principal hospital diagnoses in patients
who elected hospice within 3 days of
discharge from the hospital. In addition,
in the proposed rule we stated that our
expectation is for hospice providers to
report all coexisting or additional
diagnosis related to the terminal
prognosis and related conditions.
Comment: Several commenters said
that these statements could be
interpreted to mean that the principal
hospice diagnosis must always mirror
the hospital diagnosis and while this is
often the case, there are sometimes
specific clinical scenarios in which this
would not necessarily occur. The
commenters requested further
clarification so that hospice providers
do not feel compelled to violate their
own coding judgment just to replicate
the inpatient hospital diagnoses based
on ‘‘mandates’’ from CMS.
Response: In our statements regarding
the guidelines governing the selection of
the principal hospice diagnosis, they
were made to provide additional
guidance on the selection of the
principal diagnosis for hospice
providers based on the ICD–9–CM
Coding Guidelines. We recognize that
the principal hospice diagnosis may not
mirror the inpatient hospital diagnosis
in certain circumstances. The scenario
below, provided by a commenter, is an
example:
A patient was admitted to the hospital with
a diagnosis of pneumonia. Upon diagnostic
work-up, it was discovered that the patient
had stage 4 lung cancer. The patient opted
not to pursue curative treatment and was
discharged to home with hospice services in
place. The principal hospice diagnosis
selected for this patient was lung cancer.
This would be an appropriate principal
hospice diagnosis, though it was not the
same as the primary hospital diagnosis.
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However, in the FY 2014 hospice wage
index and payment rate update
proposed rule, we presented data
analysis where the principal hospital
diagnosis was a cancer diagnosis, but
the hospice diagnosis was not. It would
be expected that, in a cancer diagnosis,
in which the individual received
inpatient medical care for that diagnosis
and was discharged home with hospice
election within three days, that the
principal hospice diagnosis would be
the inpatient hospital diagnosis of
cancer. However, to clarify, we are not
requiring that the principal hospice
diagnosis always must be the exactly the
same as the inpatient hospital diagnosis.
We continue to reiterate that the
certifying physician, using his or her
expert clinical judgment and supporting
documentation from the clinical records
and the comprehensive assessment(s),
will determine the most appropriate
principal diagnosis, along with other,
additional related diagnoses, that are
contributing to the terminal prognosis of
the individual. Our purpose in
providing these statements in the
proposed rule was to remind providers
of the ICD–9–CM Coding Guidelines
which state, to list first the diagnosis
shown in the medical record to be
chiefly responsible for the services
provided and to list additional codes
that describe any coexisting conditions.
Comment: One commenter questioned
what the expectation is for the number
of other, additional diagnoses that
should be reported on the hospice
claim. This commenter stated that it was
not the hospice’s standard to report
diagnoses not related to the terminal
prognosis on the hospice claim. Another
commenter stated that hospice
providers historically were ‘‘cautioned
for potential enticement by covering too
many diagnoses.’’ A few commenters
expressed concern about how CMS may
use additional information of the
secondary and tertiary diagnoses for
complex patients.
Response: We do not require
hospice’s to report a specific number of
diagnoses on the hospice claims.
However, ICD–9–CM Coding Guidelines
are specific in its instructions to
providers to ‘‘code all documented
conditions at the time of the encounter/
visit, and require or affect patient care
treatment or management.’’ Therefore,
we expect that hospice providers will
adhere to these guidelines in reporting
the appropriate diagnoses to more fully
describe the Medicare hospice
beneficiaries receiving care and services
needed to palliate and manage their
terminal conditions, based on the
information from the comprehensive
assessment and individualized hospice
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plan of care. Our regulations at
§ 418.200, hospices must provide all
services reasonable and necessary for
the palliation and management of the
terminal illness and related conditions.
As noted, we require hospices to
provide virtually all the care that is
needed by terminally ill patients.
Therefore, unless there is clear evidence
that a condition is unrelated to the
terminal prognosis, all services would
be considered related. It is also the
responsibility of the hospice physician
to document why a patient’s medical
need(s) would be unrelated to the
terminal prognosis. We expect that
hospice providers will use their best
clinical judgment in determining which
diagnoses and conditions are related to
the terminal prognosis of the individual
receiving hospice care and will report
those diagnoses and conditions
accordingly on the hospice claims.
In response to the comment regarding
the diagnosis not being available at the
time of referral, we understand that a
diagnosis may not be provided at the
time of hospice referral given the
sometimes acute nature of a hospice
referral. However, upon the hospice
physician’s review of the
comprehensive assessment along with
the other clinical records, the
expectation is that a diagnosis for
hospice claims coding should be
determined based on this review along
with the hospice physician’s best
clinical judgment as to the condition
most contributory to the terminal
prognosis.
Furthermore, the expectation is to
provide the diagnostic codes on the
claim to reflect the individual’s clinical
status regardless of the number of
diagnoses to do so. There are an ample
number of diagnosis fields on the
hospice claims for reporting. Because
the hospice reimbursement is a bundled
per diem rate, there is no enticement for
reporting too many. The goal of
requesting all of the related diagnoses
on the hospice claim is to have a more
accurate picture of the Medicare hospice
beneficiary population. This accurate
picture of the Medicare hospice
population will also help to ensure that
any payment reform model that is
considered is done so in a responsible
and thoughtful manner to protect the
viability, integrity, and intent of the
Medicare Hospice Benefit and the care
philosophy of the hospice industry.
5. Transition to ICD–10–CM
In the FY 2014 Hospice Wage Index
and Payment Rate Update proposed rule
we reminded hospice providers of the
upcoming transition from ICD–9–CM to
ICD–10–CM on October 1, 2014. We
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provided additional information
regarding the transition to ICD–10–CM
that is available through the CMS Web
site at: https://www.cms.gov/Medicare/
Coding/ICD10/?redirect=/
icd10; and ICD–10–CM coding
guidelines can be found on the CDC’s
Web site at www.cdc.gov/nchs/data/
icd10/10cmguidelines2012.pdf.
Comment: We received multiple
comments asking to suspend the
enforcement of the clarifications of ICD–
9–CM Coding Guidelines until the
implementation of ICD–10–CM. It was
stated that the preparation for the
transition to ICD–10–CM was
burdensome enough for hospice
providers.
Response: The transition to ICD–10–
CM has been discussed in previous
hospice rules and notices, and the
transition deadline for ICD–10–CM has
already been pushed back until its
current October 1, 2014 implementation
date to allow for providers to have
adequate time to prepare their
administrative processes and systems.
Additionally, in our regulations at 45
CFR 162.1002, the Secretary adopted the
ICD–9–CM code set, including The
Official ICD–9–CM Guidelines for
Coding and Reporting. The CMS’
Hospice Claims Processing manual (Pub
100–04, chapter 11) requires that
hospice claims include other diagnoses
‘‘as required by ICD–9–CM Coding
Guidelines’’. Furthermore, these ICD–9–
CM Coding Guidelines have been
existing and longstanding policies that
should be adhered to by all providers.
Other health care providers in both
the inpatient and outpatient settings are
required to follow these coding
guidelines, and enforcement of these
policies has been part of their payment
systems for years. The expectation for
hospice providers to follow those same
guidelines is imperative to ensure
continuity and quality of care
throughout a Medicare beneficiary’s
health care continuum. Therefore, we
stand by our clarifications regarding the
ICD–9–CM Coding Guidelines and ICD–
10–CM Coding Guidelines. However, in
response to the comments received
regarding the additional time needed to
implement these coding clarification
changes within their software systems,
we will require these coding changes
beginning on October 1, 2014, when all
hospice claims submitted on or after
October 1, 2014 will be subject to
having claims returned if presented for
payment with incorrect codes.
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B. The Hospice Quality Reporting
Program
1. Background and Statutory Authority
Section 3004 of the Affordable Care
Act amended the Act to authorize a
quality reporting program for hospices.
Section 1814(i)(5)(A)(i) of the Act
requires that beginning with FY 2014
and each subsequent FY, the Secretary
shall reduce the market basket update
by 2 percentage points for any hospice
that does not comply with the quality
data submission requirements with
respect to that FY. Depending on the
amount of the annual update for a
particular year, a reduction of 2
percentage points could result in the
annual market basket update being less
than 0.0 percent for a FY and may result
in payment rates that are less than
payment rates for the preceding FY. Any
reduction based on failure to comply
with the reporting requirements, as
required by section 1814(i)(5)(B) of the
Act, would apply only for the particular
FY involved. Any such reduction will
not be cumulative and will not be taken
into account in computing the payment
amount for subsequent FYs.
Section 1814(i)(5)(C) of the Act
requires that each hospice submit data
to the Secretary on quality measures
specified by the Secretary. The data
must be submitted in a form, manner,
and at a time specified by the Secretary.
Any measures selected by the Secretary
must have been endorsed by the
consensus-based entity which holds a
contract regarding performance
measurement with the Secretary under
section 1890(a) of the Act. This contract
is currently held by the NQF. However,
section 1814(i)(5)(D)(ii) of the Act
provides that in the case of a specified
area or medical topic determined
appropriate by the Secretary for which
a feasible and practical measure has not
been endorsed by the consensus-based
entity, the Secretary may specify
measures that are not so endorsed as
long as due consideration is given to
measures that have been endorsed or
adopted by a consensus-based
organization identified by the Secretary.
Section 1814(i)(5)(D)(iii) of the Act
requires that the Secretary publish
selected measures applicable with
respect to FY 2014 no later than October
1, 2012.
2. Quality Measures for Hospice Quality
Reporting Program and Data Submission
Requirements for Payment Year FY 2014
The successful development of a
Hospice Quality Reporting Program
(HQRP) that promotes the delivery of
high quality healthcare services is our
paramount concern. We seek to adopt
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measures for the HQRP that promote
efficient and safer care. Our measure
selection activities for the HQRP takes
into consideration input we receive
from the Measure Applications
Partnership (MAP), convened by the
National Quality Forum (NQF), as part
of a pre-rulemaking process that we
have established and are required to
follow under section 1890A of the Act.
The MAP is a public-private partnership
comprised of multi-stakeholder groups
convened by the NQF for the primary
purpose of providing input to CMS on
the selection of certain categories of
quality and efficiency measures, as
required by section 1890A(a)(3) of the
Act. By February 1st of each year, the
NQF must provide that input to CMS.
Input from the MAP is located at:
(https://www.qualityforum.org/Setting_
Priorities/Partnership/Measure_
Applications_Partnership.aspx). For
more details about the pre-rulemaking
process, see the FY 2013 IPPS/LTCH
PPS final rule (77 FR at 53376 (August
31, 2012)).
We also take into account national
priorities, such as those established by
the National Priorities Partnership at
(https://www.qualityforum.org/npp/), the
HHS Strategic Plan https://www.hhs.gov/
secretary/about/priorities/
priorities.html), and the National
Strategy for Quality Improvement in
Healthcare located at (https://
www.healthcare.gov/news/reports/
nationalqualitystrategy032011.pdf). To
the extent practicable, we have sought
to adopt measures that have been
endorsed by the national consensus
organization, recommended by multistakeholder organizations, and
developed with the input of providers,
purchasers/payers, and other
stakeholders.
As stated in the August 4, 2011 FY
2012 Hospice Wage Index final rule (76
FR 47302, 47320), to meet the quality
reporting requirements for hospices for
the FY 2014 payment determination as
set forth in section 1814(i)(5) of the Act,
we finalized the requirement that
hospices report two measures:
• An NQF-endorsed measure that is
related to pain management, NQF
#0209. The data collection period for
this measure was October 1, 2012
through December 31, 2012, and the
data submission deadline was April 1,
2013. The data for this measure are
collected at the patient level, but are
reported to CMS in the aggregate for all
patients cared for within the reporting
period, regardless of payer.
• A structural measure that is not
endorsed by NQF: Participation in a
Quality Assessment and Performance
Improvement (QAPI) program that
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includes at least three quality indicators
related to patient care. The data
collection period for this measure was
October 1, 2012 through December 31,
2012, and the data submission deadline
was January 31, 2013. Hospices are not
asked to report their level of
performance on these patient care
related indicators, but simply to
indicate that a QAPI program with
patient care related indicators has been
implemented.
Hospices failing to report quality data
before the specified deadline in 2013,
will have their market basket update
reduced by 2 percentage points in FY
2014. Hospice programs will be
evaluated for purposes of the quality
reporting program based on whether or
not they submit data, and not based on
their performance level on required
measures.
For the FY 2014 payment
determination, hospices were asked to
provide identifying information, and
then complete a web based data entry
for the required measures. For hospices
that could not complete the web based
data entry, a downloadable data entry
form was made available upon request.
Electronic data submission will be
required for the FY 2015 payment
determination and beyond; there will be
no other data submission method
available.
3. Quality Measures for Hospice Quality
Reporting Program and Data Submission
Requirements for Payment Year FY 2015
and Beyond
In the November 8, 2012 CY 2013
Home Health Prospective Payment
System Rate Update final rule (77 FR
67068, 67133), to meet the quality
reporting requirements for hospices for
the FY 2015 payment determination and
each subsequent year, as set forth in
section 1814(i)(5) of the Act, we
finalized the requirement that hospices
report two measures:
• The NQF-endorsed measure that is
related to pain management, NQF #0209
• The structural measure:
Participation in a Quality Assessment
and Performance Improvement (QAPI)
Program that includes at least three
quality indicators related to patient care.
We did not extend the requirement that
hospices complete a check list of their
patient care indicators and indicate the
data sources they used for their quality
indicators.
In the proposed rule for FY2014 (78
FR 27823), we proposed that the
structural measure related to QAPI
indicators and the NQF #0209 pain
measure would not be required for the
hospice quality reporting program
beyond data submission for the FY 2015
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payment determination. The original
intent of the structural measure was for
hospices to submit information about
number, type, and data source of quality
indicators used as a part of their QAPI
Program. Data gathered as part of the
structural measure were used to
ascertain the breadth and context of
existing hospice QAPI programs to
inform future measure development
activities including the data collection
approach for the first year of required
reporting (the reporting period which
could result in payment reductions in
FY 2014). To date, hospices have
reported two cycles worth of structural
measure data to CMS:
• Voluntary reporting period
(submitted to CMS by January 31,
2012)—For the voluntary reporting
period hospices submitted free text data
describing each quality indicator in
their QAPI programs; data regarding
number and data source of quality
indicators were also submitted.
• FY 2014 (submitted to CMS by
January 31, 2013)—For the FY 2014
cycle, hospices submitted data about the
topic areas of care addressed by quality
indicators in their QAPI Programs, using
a drop-down menu checklist rather than
free text, in order to reduce burden. Data
regarding number and data source of
quality indicators were also submitted.
CMS has analyzed data from both
reporting periods. Findings from the
voluntary reporting period showed that
hospices use quality indicators that
address a wide range of patient care
related topics and that there is great
variation in how hospices collect and
use ‘‘standardized’’ quality indicators.
The majority of reported indicators
addressed patient safety and physical
symptom management. Likewise,
findings from analysis of the FY 2014
structural measure data reiterated
findings from the voluntary reporting
period.
Other topics addressed included
management of psychosocial aspects of
care, bereavement and grief,
communication, and care coordination.
Overall, findings from both data
collections of the structural measure
have provided adequate information on
hospice’s patient care-related indicators
making further reporting on the
structural measure unnecessary.
Comment: We received several
comments in favor of the proposal to
remove the structural measure
requirement beyond data submission for
the FY 2015 payment determination.
There were no comments in opposition
to removing the structural measure
requirement after FY 2015. One
commenter indicated that CMS should
make clear that it was only removing the
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structural measure requirement, not the
QAPI program requirement from the
Conditions of Participation.
Response: The results of the voluntary
reporting period and the analysis of the
FY 2014 structural measure data
provided adequate information about
hospices’ patient care-related quality
indicators. We are finalizing the
proposal to remove the structural
measure requirement beyond data
submission for the FY 2015 payment
determination. We are reiterating that
the requirements regarding QAPI in the
Conditions of Participation remain
intact.
As stated above, in the proposed rule,
we proposed that the NQF #0209 pain
measure not be required for the hospice
quality reporting program beyond data
submission for the FY2015 payment
determination. We determined that the
NQF #0209 measure as it is currently
collected and reported by hospices is
not suitable for long term use as part of
the Hospice Quality Reporting Program
(HQRP). In making this decision, we
considered findings from the Voluntary
Reporting Period and the Hospice Item
Set pilot. Since the publication of the
proposed rule, we examined data from
the first year of reporting on the
measure (impacting FY 2014 APU
determination). In addition, we
considered stakeholder input including
comments submitted during
rulemaking, expert input from a
Technical Expert Panel (TEP), and
provider questions and comments
submitted to the hospice quality help
desk during the 2012/2013 data
collection and reporting period. There
are two central concerns with the NQF
#0209 measure. First, the measure does
not easily correspond with the clinical
processes for pain management,
resulting in variance in what hospices
collect, aggregate, and report. This
concern could potentially be addressed
by extensive and ongoing provider
training or standardizing data
collection. However, even with
extensive training and the use of a
standardized item set during the pilot
test, the data showed continued
variance in implementation of the
measure. Second, there is a high rate of
patient exclusion due to patient
ineligibility for the measure and
patients’ denying pain at the initial
assessment. This high rate of patient
exclusion from the measure results in a
small denominator and creates validity
concerns. These concerns cannot be
addressed by training or standardizing
data collection. We recognize the value
of measuring hospices’ ability to achieve
patient comfort and the desire to
include a patient outcome measure such
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as the NQF #0209 in the HQRP. By
removing the requirement that hospices
submit the NQF #0209 measure, pain
comfort will not be measured as part of
the HQRP. However, we plan to require
that hospices collect data on two other
measures that address care for pain. The
standardized item set that CMS has
developed contains data elements to
collect 7 quality measures endorsed by
NQF for hospice. Among these are two
process measures related to pain: the
NQF #1634, Pain Screening, and NQF
#1637, Pain Assessment. However,
while these measures provide insight
about screening and assessment of
patients, they do not offer information
about patient-reported comfort related
to pain.
In the proposed rule, an alternative
proposal was made to retain NQF #0209
until a more suitable outcome measure
was available for use in the HQRP, to
maintain a focus on achieving patient
comfort. We also recognize the
importance of adherence to
standardized data collection
specifications when producing
measures for public reporting. We
intend to work toward the HQRP’s
future inclusion of an improved pain
outcome measure. We solicited
comment on the removal of the
checklist and data source questions
from the structural measure, and the
removal of the NQF #0209 measure. We
also solicited comment on the
alternative proposal of maintaining NQF
#0209 until another pain outcome
measure is available.
Comment: A large majority of
comments received agreed with the
proposal to remove the NQF #0209 pain
measure from the HQRP because of the
concerns with the measure as described
above. Commenters stated that the
measure is difficult to implement and
does not correspond with clinical
processes for pain management. One
commenter suggested that there is not
an issue with the data collection not
corresponding to hospice clinical
practice, but rather a learning curve
phenomenon. Commenters also agreed
that high rates of patient exclusion from
the measure lead to validity issues. The
majority of commenters were also
against the alternate proposal to retain
the NQF #0209 until an alternate pain
outcome measure is developed, citing
that continuing to collect it would be an
unnecessary burden on providers. Some
also commented that discontinuing data
collection for the NQF #0209 pain
measure after the CY 2013 data
collection period would permit hospices
more time to focus on preparing for the
implementation of the Hospice Item Set
(HIS) and other requirements. A few
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commenters indicated that the NQF
#0209 should be retained. Commenters
in favor of retaining the measure stated
that, though flawed, the measure has
merit because it is an outcome measure.
They also felt it has merit because it
incorporates patient preferences for pain
management and is meaningful to
consumers. Commenters also stated that
hospices invested a lot of time and
energy to establish their data collection
and submission processes for this
measure. One commenter thought CMS
should evaluate additional quarters of
data submissions by hospices to fully
evaluate the measure’s validity before
deciding whether to eliminate its use
from the HQRP.
Response: Since the release of the
proposed rule, we have analyzed the
NQF #0209 pain measure data from the
FY 2014 hospice reporting cycle.
Results from the analysis support our
central concerns with the NQF #0209
pain measure as stated above. Due to
exclusions, a very small percentage of
patients admitted to hospice would be
represented by this quality measure,
suggesting validity issues with the
measure. FY 2014 data analysis shows
that data errors affected approximately
one-third of all hospices’ data
submissions despite the use of warning
and error messages in the data
submission system. In addition, the data
showed that approximately 30 percent
of the patients who were asked the
initial comfort question ended up in the
measure denominator (the denominator
is set by patients who said ‘‘yes’’ to the
initial comfort question). The data also
showed that approximately 54 percent
of hospices had 10 or fewer admissions
during the data collection period (Q4
2012), indicating a denominator size
problem that would affect the potential
use of the measure for public reporting
purposes in the future. We will post a
document summarizing the findings
related to the NQF #0209 measure on
the cms.gov Web site at https://
www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/
index.html. The document includes
findings from the Voluntary Reporting
Period, the Hospice Item Set Pilot Test,
and the FY 2014 national reporting of
the NQF #0209 data. These three
sources of information along with
stakeholder comments during the public
comment period were considered in
finalizing the proposal to discontinue
the requirement that hospices report the
NQF #0209 measure beyond FY 2015.
We understand that hospices may
choose to use the NQF #0209 as part of
their ongoing quality improvement
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48257
efforts. However, we believe that
continuing to require hospices to report
the NQF #0209 measure beyond FY
2015 is inappropriate and burdensome.
We agree that outcome measures are
essential to the HQRP. We are
committed to developing an improved
pain outcome measure and we will
work toward the HQRP’s future
inclusion of an improved pain outcome
measure. Although we appreciate the
value of including an outcome measure
as part of the HQRP, based on the
majority of comments received and FY
2014 NQF #0209 data analysis findings,
we are finalizing the proposal to
discontinue use of the NQF #0209 pain
measure after FY 2015 reporting. We
will not finalize the alternate proposal
to retain the NQF #0209 until another
pain outcome measure is available.
4. Quality Measures for Hospice Quality
Reporting Program for Payment Year FY
2016 and Beyond
As stated in the November 8, 2012 CY
2013 Home Health Prospective Payment
System Rate Update final rule (77 FR
67068, 67133), we considered an
expansion of the required measures to
include additional measures endorsed
by NQF. We also stated that to support
the standardized collection and
calculation of quality measures,
collection of the needed data elements
will require a standardized data
collection instrument. We have
developed and tested a hospice patientlevel item set to be used by all hospices
to collect and submit standardized data
items about each patient admitted to
hospice. We contracted with RTI
International to support the
development of the Hospice Item Set
(HIS) for use as part of the HQRP. In
developing the HIS, RTI focused on the
NQF endorsed measures that had
evidence of use and/or testing with
hospice providers. Most of these
measures were initially developed
during the PEACE (Prepare, Embrace,
Attend, Communicate, and Empower)
Project, which was funded by CMS to
develop and test an initial set of quality
measures for use in hospice and
palliative care. The PEACE project,
which ended in 2008, resulted in the
identification of recommended quality
measure and data collection tools that
hospice providers could use in their
Quality Assessment and Performance
Improvement (QAPI) programs to assess
quality of care and target areas for
improvement. Additional information
on the PEACE project can be found at
https://www.thecarolinascenter.org/
default.aspx?pageid=24.
Most of the measures endorsed by
NQF are already widely in use by
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hospices nationwide as part of their
internal Quality Reporting and
Performance Improvement (QAPI)
programs. Data we received from
hospices during the Voluntary
Reporting Period in 2011 showed that
hospices had implemented and were
using the PEACE measures. Some of the
PEACE measures were endorsed by NQF
in February, 2012, and are listed below
with their NQF endorsement numbers.
The HIS standardizes the collection of
the data elements that are needed to
calculate seven of the NQF endorsed
measures. The HIS was pilot tested
during the early summer of 2012. The
primary objective of the pilot was to
explore data collection methods and the
feasibility of implementing a patientlevel item set for possible future use as
part of the HQRP.
In developing the standardized HIS,
we considered comments offered in
response to the July 13, 2012 CY 2013
Home Health Prospective Payment
System Rate Update proposed rule (77
FR 41548, 41573). We have included
data items that support the following
NQF endorsed measures for hospice:
• NQF #1617 Patients Treated with an
Opioid who are Given a Bowel
Regimen
• NQF #1634 Pain Screening
• NQF #1637 Pain Assessment
• NQF #1638 Dyspnea Treatment
• NQF #1639 Dyspnea Screening
• NQF #1641 Treatment Preferences
• NQF #1647 Beliefs/Values
Addressed (if desired by the patient)
(modified)
To achieve a comprehensive set of
hospice quality measures available for
widespread use for quality improvement
and informed decision making, and to
carry out our commitment to develop a
quality reporting program for hospices
that uses standardized methods to
collect data needed to calculate quality
measures, we proposed the
implementation of the HIS in July 2014.
We believe that to support the
standardized collection and calculation
of any or all of the hospice quality
measures listed above, it is necessary to
use a standardized data collection
mechanism. The HIS was developed
specifically for this data collection
purpose. The HIS Paperwork Reduction
Act (PRA) package is posted on the PRA
area of the CMS.gov Web site at:
https://www.cms.gov/Regulations-andGuidance/Legislation/
PaperworkReductionActof1995/
index.html.
We proposed that hospices begin the
use and submission of the HIS in July
2014. To meet the quality reporting
requirements for hospices for the FY
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2016 payment determination and each
subsequent year, we proposed regular
and ongoing electronic submission of
the HIS data for each patient admitted
to hospice on or after July 1, 2014,
regardless of payer. Hospices will be
required to complete and submit an
admission HIS and a discharge HIS for
each patient. Hospices failing to report
quality data via the HIS in 2014 will
have their market basket update reduced
by 2 percentage points in FY 2016.
Hospice programs will be evaluated for
purposes of the quality reporting
program based on whether or not they
submit data, not on their performance
level on required measures.
Comment: We received comments
that were supportive of the
implementation of the Hospice Item Set
(HIS). Commenters agreed with the need
for a standardized item set to collect
patient level information that could be
used to calculate the quality measures
endorsed by the National Quality Forum
(NQF) for hospice. However,
commenters were concerned that the
proposed July 1, 2014 date for starting
submission of the HIS was too soon, and
didn’t allow for adequate time to
prepare processes and systems for data
collection, staff training, and other
organizational preparations for
implementation, particularly in the
context of the other proposals in the
rule such as the implementation of the
hospice experience of care instrument.
Commenters noted that vendors would
have less than 12 months to create
software for providers to use to submit
the HIS data. Commenters were
concerned that there were too many
changes coming in too short a time.
Response: We appreciate the general
support of standardized data collection
and the Hospice Item Set (HIS). We are
aware of the effort hospices and vendors
will have to make to prepare for
implementation of the HIS. The HIS
pilot showed that implementing the HIS
is feasible, and that hospices are most
likely already collecting the information
needed to complete the HIS data items.
A draft version of the HIS technical data
specifications was posted on the CMS
Web site on May 24, 2013. Based on
other provider settings (for example,
Home Health Agencies and Nursing
Homes), it is our experience that when
there are changes to the draft version of
data specification the changes are minor
and few, if any, compared to the final
version of the technical data
specifications. Thus, vendors have been
provided with more than adequate time
(greater than 12 months) to develop
products for their clients. We expect
vendors to begin reviewing the draft
technical data specifications as soon as
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they are posted. We encourage vendors
to submit questions and comments to
the HIS technical email box:
HospiceTechnicalIssues@cms.hhs.gov.
On July 16, 2013, CMS held a call
specific for software developers and
vendors regarding the HIS technical
data specifications. We will hold
additional vendor calls as needed to
ensure that software vendors have the
appropriate information to develop their
own products for HIS. Software vendors
should not be waiting for final technical
data specifications to be posted to begin
development of their own products.
Therefore, we believe that vendors have
been provided with adequate time and
resources to meet the July 1, 2014
implementation date of the HIS.
CMS will provide free software for the
HIS. We will make a beta version of the
software available in May 2014 and the
final version in June 2014. Providing a
beta version for hospice agencies to
download in May will allow their staff
to become familiar with the
functionality of the tool. We will
provide training on the CMS HIS
software and the submission process.
We anticipate the training to occur in
the spring of 2014. Furthermore, in
cases where a hospice has purchased
vendor software and the product is not
available by July 1, 2014, the hospice
may download the CMS software and
submit records to the Quality
Improvement and Evaluation System
(QIES) Assessment and Submission
Processing (ASAP) system as required.
Thus, hospices will be able to comply
with the July 1, 2014 implementation
date of the HIS. We are finalizing
implementation of the HIS on July 1,
2014.
Comment: Several commenters
expressed concern over the ‘‘100
percent submission requirement’’ of the
HIS and stated that exceptions for
natural disasters and other extenuating
circumstances should be allowed. In
addition, a few commenters expressed
concern that a hospice would be
penalized if even one submission was
missed, and that there needs to be a
receipt process that would provide
proof of data submission.
Response: Submission of the HIS on
all patients admitted to hospice,
regardless of payer, is expected. As is
common in other quality reporting
programs, we will propose to make
accommodations in the case of natural
disaster or other extenuating
circumstances in next year’s
rulemaking. In addition, the data
submission system will include
validation and receipt processes that
will serve as evidence of submission.
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Comment: Some commenters
indicated that they support the
implementation of the HIS and the
endorsed measures that can be
calculated from the items on the HIS.
However, while overall supportive of
the measures and the HIS, they also
indicated concern about the length of
stay exclusion in the endorsed measures
that will be calculated from the HIS.
Commenters were also concerned that
there were no outcome measures that
will be calculated from the HIS. We also
received a few comments indicating
concern over other measure
specifications (for example, additional
exclusions for measures).
Response: To comply with the
requirements of the Affordable Care Act,
CMS seeks to implement meaningful
quality measures with demonstrated
scientific acceptability that have been
endorsed by an endorsing body,
currently the NQF. Thus, we are
somewhat, but not completely
constrained by the availability of
endorsed hospice quality measures. In
addition, in selecting and implementing
measures, we are constrained by the
measures specifications of the endorsed
measures. All of the measures that will
be implemented are endorsed with a 7day length of stay exclusion as part of
the measure specifications. Section
1841(i)(5)(D) of the Act requires us to be
deferential to measures approved by an
endorsing body such as the NQF.
However, we agree that the length of
stay exclusion in particular is of
concern because it effectively excludes
an important segment of hospice
patients from the measures. We plan to
analyze HIS data to continue to assess
the scientific acceptability of the
measures and are willing to work with
measure developers and stewards to
make modifications to measures where
needed. In addition, we support the
development of additional hospice
quality measures, particularly outcome
measures, and will seek opportunities to
use outcome measures as they are
developed and validated.
Comment: We received a few
comments indicating concern over the
potential burden of the HIS on patients
and families.
Response: The HIS is a set of data
elements that can be used to calculate
7 NQF endorsed quality measures. The
HIS is not a patient assessment and it
will not be administered to the patient
and/or family or caregivers during the
initial assessment visit. The HIS is not
intended to replace a hospice’s current
initial patient assessment. The HIS pilot
demonstrated that hospices use a variety
of patient assessment forms during the
initial patient assessment; all hospices
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were able to crosswalk items from their
patient assessment forms to the HIS data
elements, and complete the HIS items.
Therefore, the HIS did not add items to
the hospice’s customary patient initial
assessment, and did not present an
additional burden to the patient and/or
family or caregivers.
Comment: A few commenters
suggested removing the discharge HIS,
indicating that the items on the
discharge HIS are only administrative,
and provide no additional value in
terms of the quality measures while
adding burden of completion to the
hospice. Other commenters indicated
that they were pleased to see the
proposal of an admission and discharge
HIS.
Response: The discharge HIS is
needed to provide an end date for the
episode of care, and to establish the
length of stay exclusion for patients
whose hospice stay was less than 7
days. The discharge HIS items are
minimal, but necessary for accurate
records in the CMS data system and
potentially for the providers’ use with
their own QAPI activities. Vendor
software would pre-populate the
majority of these items and the hospice
would only code a few of the items on
the discharge HIS; burden on hospices
would be reduced as a result.
Comment: A few commenters voiced
concerns about potential ceiling effects
with the NQF quality measures stating
that measures may ‘‘top out.’’ Two
commenters stated that NQF #1634 Pain
Screening should not be considered for
use in the quality reporting program,
citing concerns about ceiling effects
with the measure.
Response: We recognize the
commenters’ concerns about the
appropriateness of use of quality
measures that have ‘‘topped out,’’
demonstrating ceiling effects. Ceiling
effects on quality measures would
indicate that there is little room for
improvement on the particular quality
measures across providers, rendering
the measures of little use in measuring
quality. There is currently no national
data available to determine whether any
of the proposed measures demonstrate
ceiling effects. We will analyze data
submitted to determine validity and
reliability of measures, and part of this
analysis will include analyzing for
ceiling effects. We will determine
appropriateness of measures for
retention in the quality reporting
program based on these analyses. We
appreciate commenters’ concerns about
NQF #1634 Pain Screening. However,
NQF #1634 Pain Screening and NQF
#1637 Pain Assessment are paired
measures meaning NQF #1634 is
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necessary to generate the denominator
for NQF #1637.
Comment: Two comments stated that
items for the NQF #1641 and #1647
should appear on the discharge HIS to
meet measure specifications.
Response: The NQF #1641 measure
endorsement form does not specify a
time window for the measure
numerator. The commenters are correct
that the NQF #1647 measure
endorsement form does specify that the
numerator criteria can be met any time
during the period the patient is enrolled
in the hospice program. We have
consulted NQF about our proposal to
capture the data on the admission HIS,
and have received guidance that by
limiting the time window in this way,
we are proposing to use a ‘‘modification
of the NQF #1647’’ measure. We have
opted to include the relevant items for
both the NQF #1641 and the NQF #1647
on the Admission HIS, even though the
measure specifications for the NQF
#1647 permit the numerator condition
to be met at any time during the hospice
episode of care. For multiple reasons,
CMS has opted to include the NQF
#1647 measure items as part of the
Admission HIS, reflecting the initial
period of time the patient is in hospice
care. Addressing patients’ values/beliefs
and preferences for treatment by
providing an opportunity for patients
and families to discuss their preferences
during the comprehensive assessment
period is an important step in ensuring
the delivery of hospice care that is
patient and family-centered. Including
the NQF #1647 measure items as part of
the Admission HIS also aligns with the
Conditions of Participation for hospices
at § 418.54(c), which state that the
comprehensive assessment ‘‘must
identify the physical, psychosocial,
emotional and spiritual needs related to
the terminal illness that must be
addressed in order to promote the
hospice patient’s well-being, comfort,
and dignity throughout the dying
process. . . .’’ We recognize that the
discussion can take place at any time in
the course of a patient’s hospice care but
believe the patient should be offered the
opportunity to address these concerns
in the early days of care when they are
more likely to be able to do so. We
consider it best practice. We have
chosen this approach also because it
allows the gathering of the data for the
measure closer to ‘‘real time’’ in terms
of usual hospice assessment and
workflow and because this approach
will likely improve accuracy and reduce
burden to the provider. If these items
were on the discharge HIS, hospices
would have to review the entire episode
of care documentation to find the
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information needed to complete the
relevant items on the HIS. We worked
with the measure developer to ensure
that the intent of the measure is still met
with the HIS admission data collection.
We will monitor the performance over
time to inform future evaluation for
maintenance of the measure’s
endorsement. We will proceed with the
collection of the NQF #1641 measure
and the modified NQF #1647 measure
as part of the Admission HIS.
Comment: We received a few
comments regarding what should count
towards the numerator for NQF #1641
(Treatment Preferences). Commenters
suggested that review of advance
directives count in the numerator for
these items.
Response: Discussion of patient
preferences is important to ensure that
care is individualized, patient and
family centered, and consistent with
patient and/or family preferences. The
intent of the NQF #1641 measure is to
ensure that hospices engage patients
and families in opportunities to discuss
their treatment preferences. Hospices
meet the #1641 numerator requirements
by asking the patient and/or family
about their preferences and
documenting that a discussion of
preferences occurred, or by
documenting that the patient and/or
family did not wish to discuss their
preferences. The measure endorsement
forms clearly state that the measure is
meant to capture evidence of
communication and discussion. Prior to
implementation of the HIS, we will
provide hospices with guidance and
training materials, including a detailed
user guide.
Comment: We received a comment
that NQF #1641 (Treatment Preferences)
does not mention cardiopulmonary
resuscitation (CPR) or hospitalization.
Response: The measure specifications
as endorsed by NQF do not clearly
define what constitutes preferences for
life-sustaining treatment. As such, we
included data items F2000 (CPR
Preference) and F2200 (Hospitalization
Preference) in the HIS to provide
clarification and improve usability.
These specifics are important to
measure maintenance and development
and does not stray from the measure
specifications. We will provide
guidance and training materials,
including a detailed user guide for
hospices prior to implementation of the
HIS.
Comment: For NQF #1647, one
commenter questioned which hospice
staff would be eligible to ask the patient
about concerns related to beliefs and
values to satisfy the numerator for the
measure. This commenter questions if a
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social worker or bereavement staff
member could collect the data or if it
had to be a chaplain.
Response: The measure specifications
for NQF #1647 require documentation
of a discussion between the patient and/
or family and a member of the
interdisciplinary team or clergy or
pastoral worker, or documentation that
the patient/family declined to discuss.
We will provide guidance and training
materials, including a detailed user
guide, to hospices prior to
implementation of the HIS.
Comment: We received comments
providing input about specific items on
the HIS. Commenters offered
suggestions on items in Sections A, F,
I, J, N, and Z of the HIS.
Response: We appreciate the
comments received about specific items
in the HIS. The items in Section A are
a subset of those that appear and are
standardized across data submission
vehicles in multiple CMS quality
reporting programs; they are needed for
adequate record identification in CMS
systems. Items in Sections F, I, J, and N
are all necessary to establish the
numerator and/or denominator; meet
other measure specifications for the 7
NQF endorsed measures that can be
calculated from the HIS; or for purposes
of future potential risk adjustment to the
measures.
Comment: We received several
comments regarding who the hospice
must speak with about items in Section
F (Preferences) to meet the numerator
condition for the corresponding
measures. A few commenters noted that
not all patients have caregivers.
Response: For items F2000, F2100,
and F2200, the hospice must ask the
patient or the patient’s representative if
the patient is unable to self-report. The
responsible party may or may not be a
family member or caregiver. We will
provide guidance and training materials,
including a detailed user guide to
hospices prior to implementation of the
HIS.
Comment: We received several
comments regarding Section I (Active
Diagnoses) and item I0010 (Principal
Diagnosis) that appears in this section.
Some commenters felt the item did not
include enough diagnoses to be useful
and that principal diagnoses was not
relevant to the measures. One
commenter suggested that we obtain
this data from claims or Program for
Evaluating Payment Patterns Electronic
Report (PEPPER) reports.
Response: Disease processes and
conditions impact service delivery.
Cancer and dementia/Alzheimer’s
Disease are two of the most common
principal diagnoses among hospice
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patients. We believe that this item is
important for measure maintenance and
development. The HIS applies to all
payers, which is why CMS is not relying
on claims or other available data
sources. To limit the burden on hospice
providers we chose to limit the
diagnostic categories.
Comment: We received comments
that J0900 (Pain Screening) and J0910
(Comprehensive Pain Assessment) went
beyond the measures specifications for
NQF #1634 and NQF #1637. Some
commenters did not understand the
purpose of J0900D (the patient’s pain
severity rating); others argued that
J0900D should be removed from the
item set because it incorrectly implies
that a clinician’s opinion of pain
severity is an acceptable datum. Others
questioned the inclusion of J0910C
(Comprehensive Pain Assessment
included).
Response: The NQF # 1634 and 1637
are ‘‘paired measures’’. The NQF #1634
forms the denominator for the NQF
#1637 measure. The measure
specifications for NQF #1634 require
that patients must be screened for the
presence or absence of pain (and if
present, a rating of its severity) using a
standardized tool. The measure
specifications do not require hospices to
use one particular tool or clinical
approach, in recognition of prior
stakeholder input that indicated it is
important to allow clinicians to select
and use the appropriate screening tool
on a case-by-case basis. The HIS is not
a patient assessment; it is an item set
designed to collect data elements that
can be used to calculate NQF endorsed
measures, including NQF #1634 and
#1637. As a result, item J0900D is
needed to establish whether or not the
standardized screening tool selected and
used by the clinician indicated that the
patient had pain. Details of how to code
item J0900D will be provided in the
User Guide. CMS has involved the
measure steward in developing that
User Guide. J0900 D is also needed
because it forms the denominator for
NQF #1637, pain comprehensive
assessment. The measure specifications
for NQF #1637 indicate that a
comprehensive clinical assessment
should include 5 of the following 7
characteristics of pain: location,
severity, character, duration, frequency,
what relieves or worsens the pain, and
the effect on function or quality of life.
J0910C provides a checklist of these 7
items and forms the numerator for NQF
#1637.
Comment: We received several
comments regarding J0900 (Pain
Screening) and J0910 (Pain Assessment).
Some commenters expressed that we
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should provide more clarity on
acceptable pain screening tools and
determining patient pain severity.
Regarding J0910C (Comprehensive Pain
Assessment included), one commenter
indicated that finding the elements of
the comprehensive pain assessment in
the medical record would be tedious.
Response: The measure specifications
for NQF #1634 (Pain Screening) require
that patients must be screened for the
presence or absence of pain (and if
present, a rating of its severity) using a
standardized tool. The HIS is not a
patient assessment, and we do not want
to be overly prescriptive in which
standardized pain screening tools
hospices use or how patient pain is
rated. Thus, the items listed in J0900C
(Type of standardized pain screening
tool used) are not specific screening
tools in and of themselves. Instead they
are tools that may be utilized for the
assessment of pain severity. Item J0910C
(Comprehensive pain assessment
included) helps form the numerator for
NQF #1637 (Pain Assessment) and must
be retained. We will provide guidance
and training materials, including a
detailed user guide to hospices prior to
implementation of the HIS.
Comment: We received comments on
J2030 (Screening for Shortness of
Breath) and J2040 (Treatment for
Shortness of Breath). One commenter
suggested that the respiratory screening
should require evaluation of shortness
of breath upon exertion. Another
commenter questioned the purpose of
J2040C (Type(s) of treatment for
shortness of breath initiated).
Response: The measure specifications
for NQF #1639 (Dyspnea Screening) do
not require that the respiratory
screening include evaluation upon
exertion. J2040C helps form the
numerator for NQF #1639. We believe
that this item will improve usability by
indicating the treatments/types of
treatment that may be considered
treatment for shortness of breath for
purposes of the measure numerator
condition. The HIS is not a patient
assessment, and we do not want to be
overly prescriptive in which screening
tools hospices use, particularly for
shortness of breath where there is no
accepted standardized screening or
assessment tool. We will provide
guidance and training materials,
including a detailed user guide to
hospices prior to implementation of the
HIS.
Comment: One commenter wanted to
know when N0520 (Bowel Regimen)
required a response.
Response: As noted on the draft HIS,
providers will respond to the bowel
items if a scheduled opioid and/or a
PRN opioid is initiated or continued.
Comment: We received several
comments related to Section Z (Record
Administration), particularly item
Z0400 (Signature(s) of Person(s)
Completing the Record). Commenters
were unclear on the purpose of this
section and how Z0400 should be
completed.
Response: The items in Section Z
appear in and are standardized across
data submission vehicles in multiple
CMS quality reporting programs. This
section allows providers to verify,
internally, the individuals responsible
for completing the HIS (that is the
abstracters, not those completing the
patient assessment). In accordance with
processes used in other care settings, it
is suggested that the signature page of
Section Z be retained by the hospice in
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accordance with the hospice’s policies
and procedures related to patient
information and clinical records.
Comment: Several commenters
inquired about future guidance and
training on the HIS.
Response: We will provide guidance
and training materials, including a
detailed user guide, to hospices prior to
implementation of the HIS. We plan to
provide Hospices with further
information and details about use of the
HIS. We will provide this information
through venues such as postings on the
Hospice Quality Reporting Program Web
page, Open Door Forums,
announcements in the CMS E-News,
provider training, and National Provider
calls. Electronic data submission will be
required for HIS submission in CY 2014
and beyond; there will be no other data
submission method available. We will
make available submission software for
the HIS to hospices at no cost. We will
also provide reports to individual
hospices on their performance on the
measures calculated from data
submitted via the HIS. The specifics of
the reporting system and precisely when
specific measures will be made
available have not yet been determined.
We will report to providers on the
following measures on a schedule to be
determined:
• NQF #1617 Patients Treated with an
Opioid who are Given a Bowel
Regimen
• NQF #1634 Pain Screening
• NQF #1637 Pain Assessment
• NQF #1638 Dyspnea Treatment
• NQF #1639 Dyspnea Screening
• NQF #1641 Treatment Preferences
• NQF #1647 Beliefs/Values Addressed
(if desired by the patient)
TABLE 6—SUMMARY TABLES
Data collection
Data submission
APU Impact
Measure name
Finalized in the CY 2013 HH PPS Final Rule
1/1/2013–12/31/2013 ...............
4/1/2014 .......
FY 2015 (10/1/2014) ...............
Structural/QAPI measure NQF #0209.
Finalized in this Final Rule
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7/1/2014–12/31/2014 ...............
7/1/2014–12/31/2014 ...............
7/1/2014–12/31/2014 ...............
Rolling ..........
Rolling ..........
Rolling ..........
FY 2016 (10/1/2015) ...............
FY 2016 (10/1/2015) ...............
FY 2016 (10/1/2015) ...............
7/1/2014–12/31/2014 ...............
Rolling ..........
FY 2016 (10/1/2015) ...............
7/1/2014–12/31/2014 ...............
Rolling ..........
FY 2016 (10/1/2015) ...............
7/1/2014–12/31/2014 ...............
Rolling ..........
FY 2016 (10/1/2015) ...............
7/1/2014–12/31/2014 ...............
Rolling ..........
FY 2016 (10/1/2015) ...............
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Hospice and Palliative Care—Pain Screening, NQF #1634.
Hospice and Palliative Care—Pain Assessment, NQF #1637.
Hospice and Palliative Care—Dyspnea Screening, NQF
#1639.
Hospice and Palliative Care—Dyspnea Treatment, NQF
#1638.
Patients Treated with an Opioid who are Given a Bowel Regimen, NQF #1617.
Hospice and Palliative Care—Treatment Preferences, NQF
#1641.
Beliefs/Values Addressed (if desired by patient), modified
NQF #1647.
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As stated in the August 4, 2011 FY
2012 Hospice Wage Index final rule (76
FR 47302, 47320), we finalized that all
hospice quality reporting periods
subsequent to that for Payment Year FY
2014 will be based on a CY instead of
a calendar quarter and for FY 2015 and
beyond, the data submission deadline
will be April 1st of each year. The
implementation of the HIS in July 2014
will negate the CY data collection
requirement and the April 1st data
submission deadline. We will provide
details on data collection and
submission timing prior to
implementation of the HIS.
5. Public Availability of Data Submitted
Under section 1814(i)(5)(E) of the Act,
the Secretary is required to establish
procedures for making any quality data
submitted by hospices available to the
public. The procedures ensure that a
hospice will have the opportunity to
review the data regarding the hospice’s
respective program before it is made
public. In addition, under section
1814(i)(5)(E) of the Act, the Secretary is
authorized to report quality measures
that relate to services furnished by a
hospice on the CMS Web site. We
recognize that public reporting of
quality data is a vital component of a
robust quality reporting program and are
fully committed to developing the
necessary systems for public reporting
of hospice quality data. We also
recognize it is essential that the data
made available to the public be
meaningful and that comparing
performance between hospices requires
that measures be constructed from data
collected in a standardized and uniform
manner. The development and
implementation of a standardized data
set for hospices must precede public
reporting of hospice quality measures.
Once hospices have implemented the
standardized data collection approach,
we will have the data needed to
establish the scientific soundness of the
quality measures that can be calculated
using the standardized data collection.
It is critical to establish the reliability
and validity of the measures prior to
public reporting in order to demonstrate
the ability of the measures to
distinguish the quality of services
provided. To establish reliability and
validity of the quality measures, at least
four quarters of data will need to be
analyzed. Typically the first two
quarters of data reflect the learning
curve of the providers as they adopt a
standardized data collection; these data
are not used to establish reliability and
validity. This means that the data from
Q3 and Q4 CY 2014 will not be used for
assessing validity and reliability of the
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quality measures. Data collected by
hospices during Q 1, 2 and 3 CY 2015
will be analyzed starting in CY 2015.
Decisions about whether to report some
or all of the quality measures publicly
will be based on the findings of analysis
of the CY 2015 data. In addition, as
noted, the Affordable Care Act requires
that reporting be made public on a CMS
Web site and that providers have an
opportunity to review their data prior to
public reporting. We will develop the
infrastructure for public reporting, and
provide hospices an opportunity to
review their data. In light of all the steps
required prior to data being publicly
reported, we anticipate that public
reporting will not be implemented in FY
2016. Public reporting may occur during
the FY 2018 APU year, allowing ample
time for data analysis, review of
measures’ appropriateness for use for
public reporting, and allowing hospices
the required time to review their own
data prior to public reporting. We will
announce the timeline for public
reporting of data in future rulemaking.
We welcome public comment on what
we should consider when developing
future proposals related to public
reporting.
Comment: We received a few
comments regarding what should be
considered in developing future
proposals related to public reporting of
hospice quality data. Commenters were
in favor of public reporting, and
indicated that they felt it was time to
make this information available to
consumers. Commenters also indicated
that they appreciate the opportunity to
review their data prior to the initiation
of public reporting, and CMS’s efforts to
ensure that public reporting would not
occur before adequate data analysis had
taken place to establish the suitability of
the measures for public reporting
purposes. A few commenters suggested
that outcome measures and measures
from the family experiences of hospice
care survey would be more meaningful
for public reporting than the measures
from the HIS. Several commenters had
concerns about which of the NQF
measures proposed would be
appropriate for public reporting.
Commenters noted that all of the NQF
measures proposed were process
measures and it may ‘‘take effort’’ for
the public to understand the
relationship of process measures to
quality of care. One commenter stated
that a comprehensive explanation of
this relationship should be provided to
the public.
Response: We appreciate and
recognize commenters’ concerns about
appropriateness of quality measures for
public reporting. As stated in the
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proposed rule, we will analyze data for
validity and reliability of quality
measures and review measures’
appropriateness for public reporting
prior to determining which measures
will be publicly reported. Moreover, we
appreciate the suggestion to provide a
comprehensive explanation of
relationships between quality measures
selected for public reporting and quality
of care. We will consider this suggestion
when developing processes, procedures
and future proposals for public
reporting. We also recognize the
importance of outcome data, both for
quality measurement and for public
reporting. We also reiterate that we are
committed to seeking opportunities to
use outcome measures—both as part of
the quality reporting program and for
public report—as they are developed
and become endorsed by NQF.
6. The CMS Hospice Experience of Care
Survey for the FY 2017 Payment
Determination and That of Subsequent
Fiscal Years
Background
In the CY 2013 Home Health
Prospective Payment System Rate
Update final rule (77 FR 67135), we
stated that were considering the use of
a patient/family experience of care
survey in addition to other hospice
quality of care (clinical) measures. We
have developed a draft Hospice
Experience of Care Survey questionnaire
drawing heavily on questionnaires in
the public domain such as the Family
Evaluation of Hospice Care (FEHC). We
are testing the draft survey in a national
field test in fall 2013. The Hospice
Experience of Care Survey will treat the
dying patient and his or her informal
caregivers (family members or friends)
as the unit of care.
Before the development of this
survey, there was no official national
standard experience of care survey that
included standard survey
administration protocols. The Hospice
Experience of Care Survey will include
detailed survey administration protocols
which will allow for comparisons across
hospices. The survey will focus on
topics that are important to hospice
users and for which informal caregivers
are the best source for gathering this
information. In addition, the ‘‘About
You’’ section of the instrument includes
demographic characteristics of the
patients and their caregivers which can
be used to feed into case mix
adjustments of the publicly reported
data.
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Description of the Survey
The Hospice Experience of Care
Survey will seek information from
informal caregivers of patients who died
while enrolled in hospices. We plan to
field the questionnaires after the
patient’s death. Fielding timelines will
be established to give the respondent
some recovery time (two to three
months), while simultaneously not
delaying so long that the respondent is
likely to forget details of the hospice
experience. Caregivers will be presented
with a set of standardized questions
about their own experiences and the
experiences of the patient in hospice
care. During national implementation of
this survey, hospices will be required to
offer the survey, but individual
caregivers will respond only if they
voluntarily chose to do so.
The Hospice Experience of Care
Survey captures such topics as hospice
provider communications with patients
and family members, hospice provider
care, and patient and family member
characteristics. The survey will allow
the informal caregiver (family member
or friend) to provide an overall rating of
the hospice care their patient received,
and will ask if they will recommend
‘‘this hospice’’ to others.
The Hospice Experience of Care
Survey is following the principles used
in the development of the Consumer
Assessment of Healthcare Providers and
Systems (CAHPS®) surveys. Therefore,
we are—
• Obtaining input from consumers
and stakeholders regarding how hospice
patients perceive hospice care and what
elements in hospice programs are of
greatest importance to patients and
informal caregivers.
• Drafting a version of the hospice
questionnaire that will be cognitively
tested with a small number of
respondents in both English and
Spanish. This type of testing will allow
us to assess how respondents interpret
and respond to individual questionnaire
items.
• Providing a field test of the Hospice
Experience of Care Survey instrument
after the development of an initial
questionnaire is completed. This field
test will allow us to review survey
implementation procedures and use
statistical analysis of the survey results
to select the final set of questions. In
addition, it will allow us to select
variables which may be used in the case
mix adjustment of survey results for
public reporting.
The Hospice Experience of Care
Survey, as well as the CAHPS® family
of surveys, focuses on patient
perspectives on the experience of care,
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rather than on patient satisfaction.
CAHPS® data complements other data,
including clinical measures. CAHPS®
surveys are specifically intended to
focus on issues where the patient (or in
this case the caregiver) is the best source
of information. We intend the Hospice
Experience of Care Survey to have a
similar focus. Once the survey is final,
we will submit it for CAHPS®
endorsement and National Quality
Forum endorsement.
We plan to move forward with a
model of survey administration in
which we will approve and train survey
vendors to administer the survey on
behalf of hospices. This will be very
similar to the models that we use for
Hospital CAHPS® (HCAHPS) and Home
Health CAHPS® (HHCAHPS). Hospices
will be required to contract with an
approved survey vendor and to provide
the sampling frame to the approved
vendor on a monthly basis.
Participation Requirements for the
Survey Begin in CY 2015 for the FY
2017 Payment
We proposed that we would begin
required implementation of the survey
in January 2015 in the FY 2014 Hospice
Wage Index and Payment Rate Update;
Hospice Quality Reporting
Requirements; and Updates on Payment
Reform proposed rule (78 FR 27823,
published May 10, 2013). We are
finalizing the proposed timeline due to
the importance of the caregiver’s voice.
Beginning in first quarter of CY 2015,
hospices will be required to conduct a
dry run of the survey for at least one
month in January 2015, February 2015,
or March 2015. Beginning in April 2015,
all hospices will be required to
participate in the survey on an ongoing
basis. The one ‘‘dry run month,’’ plus
the nine months of April 2015 to
December 2015 participation, will be
required to meet the pay for reporting
requirement of the Hospice Quality
Reporting Program for the FY 2017
annual payment update.
Approved Hospice Experience of Care
Survey vendors will submit data on the
hospice’s behalf to the CMS hospice
patient experience of care survey data
center. The deadlines for data
submission have not yet been finalized.
For the ‘‘dry run’’ the survey vendor
would follow all the national
implementation procedures, but the
data would not be publicly reported.
The dry run would provide hospices
and their vendors with the opportunity
to work together under ‘‘test’’
circumstances. We will allow
exemptions for very small hospices.
Hospices that have fewer than 50
unduplicated or unique deceased
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patients in the period from January 1,
2014 through December 31, 2014 will be
exempt from the Hospice Experience of
Care Survey data collection and
reporting requirements for the FY 2017
payment determination. The hospices
would be required to submit their
patient counts for the period of January
1, 2014 through December 31, 2014 to
CMS. The due date for the participation
exemption form will be stated in next
year’s rule. To qualify for the small size
exemption, hospices will need to submit
to CMS their patient counts annually for
each future APU period.
As part of the national
implementation, we will develop
technical specifications for vendors to
follow and will issue a detailed survey
guidelines manual prior to the dry run
months.
In addition, there will be a Web site
devoted specifically to the Hospice
Experience of Care Survey. It will
include information and updates
regarding survey implementation and
technical assistance. Hospices interested
in viewing similar model Web sites are
encouraged to visit the HCAHPS Web
site at www.hcahpsonline.org or the
HHCAHPS Web site at https://
homehealthcahps.org. On these Web
sites, viewers can see and download the
detailed manuals about the surveys (the
Quality Assurance Guidelines for
Hospital CAHPS® and the Protocols and
Guidelines Manual for Home Health
Care CAHPS®), as well as obtain
information about the surveys’ histories,
data submission information, and
survey updates.
Consistent with our other
implemented surveys, we will provide
an email address and toll-free telephone
number for technical assistance.
The Affordable Care Act requires that
beginning with FY 2014 and each
subsequent FY, the Secretary shall
reduce the market basket update by 2
percentage points for any hospice that
does not comply with the quality data
submission requirements with respect to
the FY. Any such reduction would not
be cumulative and would not be taken
into account in computing the payment
amount for subsequent FYs. In the
November 8, 2012 CY 2013 Home
Health Prospective Payment System
final rule (77 FR 67068), it was stated
that all hospice quality reporting
periods subsequent to that for Payment
Year 2014 would be based on a CY
rather than on a FY. We are finalizing
adding the Hospice Experience of Care
Survey to the Hospice Quality Reporting
Program requirements for the FY 2017
payment determination. To meet the FY
2017 requirements, hospices would
participate in a dry run for at least 1
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month of the first quarter of CY 2015
(January 2015, February 2015, March
2015) and hospices must collect the
survey data on a monthly basis for the
months of April 1, 2015 through
December 31, 2015 in order to qualify
for the full APU.
The following is a summary of the
comments we received regarding the
Hospice Experience of Care Survey
proposal.
Comment: We received a number of
comments that the timeline for
implementation of the Hospice
Experience of Care Survey placed it too
close in proximity to the
implementation of the HIS items and
that there should be a gap of at least 12
months between the HIS
implementation and the survey
implementation dates.
Response: We carefully reviewed the
comments asking for a delay in the
timing of the national implementation
of the Hospice Experience of Care
Survey. However, we concluded that
obtaining data from caregivers is so
important that we cannot delay. As
proposed we will begin with a dry run
in the first quarter of 2015. Continuous
data collection will begin April, 1, 2015
for the 2017 APU.
Comment: We received comments
that there are financial and
administrative burdens on hospices
participation in the Hospice Experience
of Care Survey. Commenters also stated
that the financial burden of
participation would outweigh the 2
percent reduction in the annual
payment update that would be given to
non-participating hospices. We also
received comments stating that this
would require more staffing and the
development of a process to handle the
implementation of the survey and
comments that this is a burden to small
hospices. We received a comment
asking if hospices can self-administer
the survey to save costs in
implementing the hospice survey. In
addition, we received a comment that
the Family Evaluation of Hospice Care
(FEHC) survey does not pose a financial
burden to hospices because the FEHC
survey is a benefit of National Hospice
and Palliative Care Organization
(NHPCO) membership.
Response: We appreciate the
comments concerning that the proposed
survey is a financial burden to
participating hospices. We are using the
same survey implementation model that
we use for other CAHPS® surveys where
providers pay approved survey vendors
to conduct the data collection on their
behalf and CMS pays for the survey
vendor training, technical support and
assistance for hospices and their
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approved survey vendors, oversight of
the approved survey vendors, the public
reporting of the data, and the data
analysis of the hospice survey data.
Before national implementation begins
in 2015, hospices are strongly
encouraged to shop around for the best
cost value for them before contracting
with an approved survey vendor to
conduct the Hospice Experience of Care
Survey on their behalf. Hospices cannot
self-administer the survey because we
need to eliminate any potential bias in
the administration of the survey. We do
not believe that the annual burden to
hospices will exceed the annual burden
and costs that we see in the
implementation of HHCAHPS.
Basically, once national implementation
starts, hospices will need to choose a
vendor and contract with them, and
then they will be responsible on a
monthly basis to produce a file of all the
caregivers (the persons on the records
for the hospice patients) for hospice
patients who died in the past month.
We are not surveying people who have
living hospice patients. We cannot fully
comment on whether the survey costs to
the individual hospice providers will
outweigh the costs of the loss of 2
percent of the APU. However, most
survey costs will be much less than the
loss of the 2 percent reduction in the
APU. Small hospices serving 50 or
fewer patients in an annual period will
complete (annually) a Participation
Exemption Request Form so that they
will not incur survey costs. The CMS
hospice survey will require the
approved survey vendors to implement
the survey in accordance to a uniform
set of protocols and guidelines to assure
consistency in the survey
administration, in the implementation
of other CMS CAHPS® surveys, such as
HCAHPS, and HHCAHPS.
Comment: We received comments
that the draft hospice experience of care
survey instrument is too long and
‘‘daunting’’ to read and respond to.
Response: This is a survey that is
going to be used in a national field test
in fall 2013. There are more questions
in this test survey than we intend to
keep in the final survey. We anticipate
that we will eliminate questions that do
not contribute to the composites
measuring key areas of the hospice care
experience. We do anticipate keeping all
of the demographic questions, because
they will be used to adjust the results
for differences in the mix of patients
across hospices and for analysis of
disparities of care. It is important that
the data are adjusted to ensure accurate
comparisons across hospices. We
actually anticipate that the final survey
instrument will be significantly shorter
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than the FEHC, which has 54 items, and
a shorter instrument will translate into
lower vendor costs for the participating
hospices. To give an example of this, the
field test version of the HHCAHPS
survey had 54 items and the final
approved version of the survey that we
use today, has 34 items.
Comment: We received a comment
expressing the preference that NHPCO
be allowed to be a survey vendor for the
Hospice Experience of Care Survey.
Response: We will be using survey
vendor eligibility criteria that are very
similar or identical to our other
CAHPS® surveys, and if NHPCO meets
the stated survey vendor eligibility
criteria then we welcome NHPCO to
complete the survey vendor application
for the hospice experience of care
survey.
Comment: We received comments
that we are administering the survey too
close to the death of the patient.
Response: We thank you for this
comment. We are sensitive that a survey
about this issue will be difficult for the
families and friends of their loved ones
who have passed, especially in the first
year following the deaths. We anticipate
administering the survey about two or
three months following the deaths of the
hospice patients. We are hesitant about
waiting too long following the deaths
because the survey respondents may
forget the details of the hospice
experiences if the survey is
administered too long following the
deaths.
Comment: We received several
comments supporting CMS for
developing a new survey instrument
that is independent of existing hospice
survey instruments, and that has the
uniform survey implementation
guidelines of the CAHPS® surveys.
Response: We appreciate this support
of the CMS survey instrument. We are
following the CAHPS® guidelines and
we will apply for CAHPS® endorsement
as well as the endorsement of the
National Quality Forum. Commenters
supporting us noted that the final
survey instrument will be shorter and
that we will allow flexibilities in the
implementation of the survey that will
allow hospices to add their own
questions, but that the core questions
will be used for valid comparisons
across hospices because we will define
the protocols and guidelines for the
implementation of the survey to create
an equal implementation process for the
survey.
Comment: We received a comment
that we cannot regulate payment based
on what the living family members
think of hospice care because it is not
possible to make everyone happy and
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asking about this experience post death
seems odd and could result in a larger
percentage of negative responses.
Response: We appreciate this
viewpoint. However, the survey itself
does not focus on the death. It focuses
on the hospice care and the details
about the experience of care with the
hospice. The survey’s purpose is to
provide useful information to other
caregivers and families who are in the
position of comparing hospices for the
care of their loved ones.
Comment: We received a comment
that there are many family and friends
at the time of the death but that they
may not be present after the death when
the survey goes out. We also received a
comment that some hospices will send
out multiple surveys to family members
who had perceived good experiences,
and conversely, will not send out
surveys to family members who are
mentally ill, or were not involved in the
hospice patient’s care, even if they were
listed as the closest relative. We
received a comment that the results may
be skewed by the family member’s
degree of contact with the patient and
hospice team.
Response: We appreciate these
sensitive comments concerning who
will be the survey respondent. We
propose to have a uniform standard for
the designation of the survey
respondent. We propose that the survey
respondent will be the person who is
listed in the hospice record as the
primary caregiver or primary contact
person for the hospice patient.
Comment: We received a comment
that surveys should not be sent more
than two times to families as there is a
need not to be too intrusive.
Response: For the field test, we will
have one survey mode, called the mixed
mode that includes both a mail survey
and telephone follow-up for nonrespondents. If the survey respondent
does not return the mailed
questionnaire, then the survey
respondent is called and asked to
complete the telephone survey
instrument. For national
implementation of the survey, we will
have three modes: Mail only, telephone
only, and mixed. For the mail only
mode, only two surveys are mailed to
the sampled person. For the telephone
only mode, there will be up to five call
attempts to reach the sampled
respondent, but once the sampled
respondent answers the telephone and
speaks with the telephone surveyor, the
respondent will only be asked to
complete the survey once.
Comment: We received comments
that rural hospices will be at a
disadvantage paying for the Hospice
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Experience of Care Survey, and that
there should not be a 2 percent
reduction since hospices save money for
Medicare.
Response: We are requiring the survey
for all hospices, to meet the goals of
transparency for hospices regardless of
their location. We believe that the
burden to rural and urban hospices is
equal, and we reiterate that small
hospices serving 50 or fewer in a given
year will be exempt from survey
participation if they complete the
survey’s Participation Exemption
Request form for each APU.
Comment: We received a comment
asking if CMS would require the survey
to be available in other languages, such
as Spanish.
Response: Vendors will be required to
offer the survey in English and Spanish.
Hospices will be able to administer the
survey in additional languages if needed
for their patient populations; however,
they must use the CMS official
translations. We plan to make additional
translations of the survey available as
needed. If you would like to request a
specific translation, please email CMS at
hospicesurvey@cms.hhs.gov.
Comment: We received a comment
stating that it is not clear whether
hospices are given the full credit for
survey participation regardless of the
survey results.
Response: We stated in the proposed
rule that survey participation is required
for the full APU; the data results are not
part of the requirements for the APU.
The survey requirement is part of the
Hospice Quality Reporting Program; this
is not a pay for performance program.
Comment: We received a comment
stating that their vendor for the FEHC
notifies them immediately about
negative comments that are received
about their hospice. This commenter
noted that there is no information in the
proposed rule that describes how the
comment section of the proposed survey
will be used, or available to the hospice
paying for survey service.
Response: Hospices will still be able
to have this arrangement with their
respective vendors in the CMS Hospice
Experience of Care Survey.
Comment: We received a comment
asking if hospices will be responsible
for a certain response rate for the
Hospice Experience of Care Survey.
Response: No, hospices will not be
responsible for a certain response rate
for the Hospice Experience of Care
Survey. However, all approved survey
vendors must follow the survey
administration protocols to implement
the survey.
Comment: We received a comment of
support for the FEHC survey and
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questions about why CMS is mandating
the new survey in place of the FEHC.
We also received a comment that CMS
should allow the FEHC to be substituted
for the CMS Hospice Survey.
Response: We respect the work that
went into the FEHC; however, we
cannot allow the FEHC to substitute for
the CMS survey. To be useful to the
public, Hospice Survey data must be
comparable across hospices. Two
different surveys would create
inconsistencies among hospices that
would not allow for direct comparisons.
In addition, the FEHC was designed by
and for a private entity. CMS must
ensure that no private entity has a
preferred relationship with the agency.
The CMS survey was developed under
the standards of the CAHPS® surveys
and will be implemented with the
rigorous guidelines of the CAHPS®
surveys.
Comment: A commenter stated that
the dry run should be 3 months, instead
of 1 month.
Response: The requirement for the dry
run is 1 month, but hospices are
allowed to do 2 or 3 months, in the
period of January through March 2015.
Comment: We received a comment
that consideration needs to be given to
the diverse audiences responding to the
survey. Issues related to primary
language, socioeconomic status, culture,
and health literacy, may impact the
completion of the survey and the
responses to the survey questions.
Response: We agree with this
commenter and will adjust the survey
results for respondent mix. We will also
be offering multiple translations and
different modes of survey
administration so hospices can choose
what meets their needs the best.
Comment: We received a comment
that consideration needs to be given to
the smaller agency where one negative
survey can skew the data results for that
agency.
Response: For other CAHPS® surveys,
we have received comments about the
comparability of the data for small
providers with large providers. In the
practice of statistics, it is established
that the sample size in absolute
numbers is more important than the
proportion of the population surveyed.
Surveying a sample of 300 will produce
the same level of precision whether the
sample large or small. The larger the
sample, the less the variability is a
provider’s ratings over time. We will be
proposing the required sample sizes for
all hospices in next year’s proposed
rule. Small agencies will need to
conduct census sampling if they do not
qualify for the size exemption.
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Comment: We received a comment
that CMS needs to know what its
ultimate goal is of the surveys without
losing sight of the goal itself.
Response: The goals of the Hospice
Experience of Care Survey are the same
as the goals of our other CAHPS®
surveys: (1) To produce comparable data
on the caregiver’s or loved one’s’
perspectives on care that allow objective
and meaningful comparisons between
hospices on domains that are important
to consumers; (2) to create incentives for
hospices to improve their quality of care
through public reporting of survey
results; and (3) to enhance public
accountability in health care by
increasing the transparency of the
quality of the care provided in return for
the public investments. CMS is serious
about these three goals for all of our
perspectives of care/CAHPS® surveys,
and we intend to never lose sight of
their importance.
Comment: We received a comment
that the first portion of the survey is
nearly identical to HHCAHPS, while the
latter portion seems more representative
of hospices. This commenter stated that
questions regarding goals of care or the
patient’s plan of care were absent, two
areas of particular importance for
hospices. This commenter also noted
that questions regarding after-hour
response to needs were absent, an area
known to create much anxiety for
patients and families.
Response: We reviewed both surveys
side-by-side and disagree with this
commenter about the similarity to
HHCAHPS. We have some similar
questions, but this is because in focus
groups and later testing these issues
were all raised by our testing
participants. Also, we have many
questions about care. We also have
questions about after-hour response to
needs. They are: ‘‘While your family
member was in hospice care, did you
need to contact the hospice team during
evenings weekends or holidays for
questions or help with your family
member’s care?, and ‘‘How often did
you get the help you needed from the
hospice team during evenings,
weekends, or holidays?
Comment: We received a comment
about transitioning from the current
FEHC program to the CMS Hospice
Survey.
Response: We do not have any
relationship to the FEHC program.
Hospices can continue to continue to
use the FEHC. However, the FEHC
cannot be substituted for the CMS
Hospice Experience of Care Survey.
Hospices can conduct both surveys
under specific conditions that will be
detailed in the CMS Hospice Survey
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Guidelines Manual, which has not been
written.
Comment: We received a comment
that the survey should meet the quality
needs of individual hospices.
Response: We hope that the survey
will serve the quality needs of all
hospices. However, hospices may have
unique quality needs and hospices will
be permitted to add their own
additional questions to the standardized
survey.
Comment: We received comments
that the caregiver of record is not always
the best person to receive the survey.
Response: We are aware the caregiver
of record may not be the best person to
receive the survey. However, because
the hospice is likely to have contact
information for this person, they are the
best person for us to contact.
Comment: We received comments
expressing the concern that collecting
demographic information from
respondents could reduce response,
especially from minority populations. In
addition, commenters said that asking
for this information could raise privacy
and confidentiality concerns. We
received a comment suggesting CMS
redesign the Hospice Experience of Care
Survey so that there were no survey
questions about demographic
characteristics. The commenter has
received feedback that no one likes to
answer those kinds of questions.
Response: We ask for demographic
information on surveys for two
purposes: First, to allow us to make case
mix adjustments so that hospices’
survey responses can be compared
fairly. We have not determined how
case mix adjustments will be calculated
for this survey, and therefore, need
demographic variable to test different
case mix adjustment variables. Second,
we also need demographic information
to allow for research on health care
disparities between groups of people,
including minorities. All sampling data,
which will include these items, will be
treated as private and confidential. The
approved survey vendors who conduct
these surveys will be responsible for
maintaining the security, privacy and
confidentiality of sampling information
and survey results in accordance with
HIPAA requirements. Above all, the
completion of the survey is voluntary
for all persons who receive the survey
in the mail, or who are telephoned and
are asked to complete the survey on the
telephone. Any person who receives the
survey, or who is telephoned and is
asked to complete the survey, is free not
to complete the survey.
Comment: We received a comment
that the survey data should be adjusted
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for length of hospice stay and for the
care setting.
Response: We will use the data from
the field test to determine if the
administrative data (such as length of
stay and hospice setting) has an impact
on the survey data results.
Comment: We received comments
that CMS should not exempt very small
rural hospices from the requirements.
Response: Besides the burden to these
hospices, there is the issue of privacy to
the respondents. In very small settings,
it could be apparent who the survey
respondents are. Also, there are
sampling and reliability issues because
the sample and the data could be very
small.
Comment: We received comments
stating that it is going to be very difficult
for survey respondents to complete the
survey if their loved ones changed
hospice settings.
Response: At the beginning of the
survey, respondents are instructed to
reply to the questionnaire as pertaining
to the last setting of hospice care.
Comment: We received comments
suggesting that CMS add questions to
the survey. The suggested topics for
added items include questions
specifically relevant to veterans as well
as questions about care planning, care
goals, and volunteers.
Response: One of the concerns often
expressed to us is that the CMS Hospice
Experience of Care Survey is too long.
We intend to shorten the survey after
the field test. In this context, we are
reluctant to add still more questions to
the core survey instrument. However,
we know that it can be important for
providers to ask questions that are not
on the approved core survey instrument.
Hospices will be permitted to add their
own questions to the survey, following
the required core set of questions.
Comment: We had one comment that
suggested the follow-up schedule for the
field test of the Hospice Experience of
Care Survey was too aggressive and
would make family members or friends
of the deceased feel harassed.
Response: Our follow-up plan for the
field test is very typical for professional
mixed-mode surveys. We plan to mail a
survey to the sample members. Sample
members who have not responded
within three weeks will receive followup telephone calls. We will make up to
a maximum of five telephone calls, at
different days and times, in an effort to
reach the sample member. If we have
not reached the sample member after
five attempts, calls will be curtailed. If
the sample member is reached but
refuses to complete the survey, no more
calls will be made. We will not
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repeatedly call the sample member and
ask for a response.
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Summary of Final Rule Changes for the
Hospice Experience of Care Survey
As a result of these comments, we are
finalizing the requirements as proposed.
Hospices must participate in and report
data from a dry run for at least 1 month
in the first quarter of CY 2015 (January
2015, February 2015, or March 2015)
with continuous monthly data
collection beginning in April 1, 2015
and continuing through December 31,
2015.
7. Notice Pertaining to Reconsiderations
Following APU Determinations
At the conclusion of any given quality
data reporting period, we will review
the data received from each hospice
during that reporting period to
determine if the hospice has met the
reporting requirements. Hospices that
are found to be non-compliant with the
reporting requirements set forth for that
reporting cycle could receive a
reduction in the amount of 2 percentage
points to their annual payment update
for the upcoming payment year.
We are aware that there may be
situations when a hospice has evidence
to dispute a finding of non-compliance.
We further understand that there may be
times when a provider may be
prevented from submitting quality data
due to the occurrence of extraordinary
circumstances beyond their control (for
example, natural disasters). It is our goal
not to penalize hospice providers in
these circumstances or to unduly
increase their burden during these
times.
Other CMS Quality Reporting
Programs, such as Home Health Quality
Reporting and Inpatient Quality
Reporting, include an opportunity for
providers to request a reconsideration
pertaining to their APU determinations.
We are aware of the potential need for
providers to request reconsideration and
that we will be making APU
determinations for FY 2014 in the
coming months. Therefore, to be
consistent with other established quality
reporting programs, we used the
proposed rule to notify providers of our
intent to provide a process that would
allow hospices to request
reconsiderations pertaining to their FY
2014 and subsequent years’ payment
determinations.
Specifically, as part of the
reconsideration process for hospices
beginning with the FY 2014 payment
determinations, hospices found to be
non-compliant with the reporting
requirements during a given reporting
cycle would be notified of that finding.
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The purpose of this notification is to put
hospices on notice of the following: (1)
That they have been identified as being
non-compliant with section 3004 of the
Affordable Care Act for the reporting
cycle in question; (2) that they would be
scheduled to receive a reduction in the
amount of 2 percentage points to the
annual payment update to the
applicable fiscal year; (3) that they may
file a request for reconsideration if they
believe that the finding of noncompliance is erroneous, or that if they
were non-compliant, they have a valid
and justifiable excuse for this noncompliance; and, (4) that they must
follow a defined process on how to file
a request for reconsideration, which
would be described in the notification.
Upon the conclusion of our review of
each request for reconsideration, we
would render a decision. We could
reverse our initial finding of noncompliance if: (1) The hospice provides
proof of full compliance with the all
requirements during the reporting
period; or (2) the hospice was not able
to comply with requirements during the
reporting period, and it provides
adequate proof of a valid or justifiable
excuse for this non-compliance. We
would uphold our initial finding of noncompliance if the hospice could not
show any justification for noncompliance.
C. FY 2014 Hospice Wage Index and
Rates Update
1. Hospice Wage Index
The hospice wage index is used to
adjust payment rates for hospice
agencies under the Medicare program to
reflect local differences in area wage
levels based on the location where
services are furnished. The hospice
wage index utilizes the wage adjustment
factors used by the Secretary for
purposes of section 1886(d)(3)(E) of the
Act for hospital wage adjustments and
our regulations at § 418.306(c) require
each labor market to be established
using the most current hospital wage
data available, including any changes by
the Office of Management and Budget
(OMB) to the Metropolitan Statistical
Areas (MSAs) definitions. We have
consistently used the pre-floor, prereclassified hospital wage index when
deriving the hospice wage index. In our
August 4, 2005 FY 2006 Hospice Wage
Index final rule (70 FR 45130), we began
adopting the revised labor market area
definitions as discussed in the OMB
Bulletin No. 03–04 (June 6, 2003). That
bulletin announced revised definitions
for MSAs and the creation of Core-Based
Statistical Areas (CBSAs). The bulletin
is available online at https://
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www.whitehouse.gov/omb/bulletins/
b03-04.html. In the FY 2006 Hospice
Wage Index final rule (70 FR 45139), we
implemented a 1-year transition policy
using a 50/50 blend of the CBSA-based
wage index values and the MSA-based
wage index values for FY 2006. The
one-year transition policy ended on
September 30, 2006. For the FY 2007
hospice wage index and beyond, we
have used CBSAs exclusively to
calculate wage index values. OMB has
published subsequent bulletins
regarding CBSA changes. The OMB
bulletins are available at https://
www.whitehouse.gov/omb/bulletins/
index.html.
When adopting OMB’s new labor
market designations in FY 2006, we
identified some geographic areas where
there were no hospitals, and thus, no
hospital wage index data, which to base
the calculation of the hospice wage
index. We also adopted the policy that,
for urban labor markets without a
hospital from which hospital wage
index data could be derived, all of the
CBSAs within the state would be used
to calculate a statewide urban average
pre-floor, pre-reclassified hospital wage
index value to use as a reasonable proxy
for these areas in our August 6, 2009 FY
2010 Hospice Wage Index final rule (74
FR 39386). In FY 2014, the only CBSA
without a hospital from which hospital
wage data could be derived is 25980,
Hinesville-Fort Stewart, Georgia.
In our August 31, 2007 FY 2008
Hospice Wage Index final rule (72 FR
50214), we implemented a new
methodology to update the hospice
wage index for rural areas without a
hospital, and thus no hospital wage
data. In cases where there was a rural
area without rural hospital wage data,
we used the average pre-floor, prereclassified hospital wage index data
from all contiguous CBSAs to represent
a reasonable proxy for the rural area. In
our August 31, 2007 FY 2008 Hospice
Wage Index final rule, we noted that we
interpret the term ‘‘contiguous’’ to mean
sharing a border (72 FR 50217).
Currently, the only rural area without a
hospital from which hospital wage data
could be derived is Puerto Rico.
However, our policy of imputing a rural
pre-floor, pre-reclassified hospital wage
index based on the pre-floor, prereclassified hospital wage index (or
indices) of CBSAs contiguous to a rural
area without a hospital from which
hospital wage data could be derived
does not recognize the unique
circumstances of Puerto Rico. While we
have not identified an alternative
methodology for imputing a pre-floor,
pre-reclassified hospital wage index for
rural Puerto Rico, we will continue to
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evaluate the feasibility of using existing
hospital wage data and, possibly, wage
data from other sources. For FY 2008
through FY 2013, we have used the
most recent pre-floor, pre-reclassified
hospital wage index available for Puerto
Rico, which is 0.4047. In this final rule,
for FY 2014, we will continue to use the
most recent pre-floor, pre-reclassified
hospital wage index value available for
Puerto Rico, which is 0.4047.
For the FY 2014 Hospice Wage Index
and Payment Rate Update proposed rule
(78 FR 27840), we proposed to use the
2013 pre-floor, pre-reclassified hospital
wage index to derive the applicable
wage index values for the FY 2014
hospice wage index. We proposed to
continue to use the pre-floor, prereclassified hospital wage data as a basis
to determine the hospice wage index
values because hospitals and hospices
both compete in the same labor markets,
and therefore, experience similar wagerelated costs. We believe the use of the
pre-floor, pre-reclassified hospital wage
index data as a basis for the hospice
wage index results in the appropriate
adjustment to the labor portion of the
costs. The FY 2014 hospice wage index
values presented in this final rule were
computed consistent with our pre-floor,
pre-reclassified hospital wage index
policy (that is, our historical policy of
not taking into account Inpatient
Prospective Payment System (IPPS)
geographic reclassifications in
determining payments for hospice). The
2013 pre-floor, pre-reclassified hospital
wage index does not reflect OMB’s new
area delineations, based on the 2010
Census, as outlined in OMB Bulletin
13–01, released on February 28, 2013.
Moreover, the final FY 2014 pre-floor,
pre-reclassified hospital wage index
does not contain OMB’s new area
delineations because those changes
were not published until the IPPS
proposed rule was in advanced stages of
development (78 FR 27552). CMS
intends to propose changes to the FY
2015 hospital wage index based on the
newest CBSA changes in the FY 2015
IPPS proposed rule. Therefore, if CMS
incorporates OMB’s new area
delineations, based on the 2010 Census,
in the FY 2015 hospital wage index,
those changes would also be reflected in
the FY 2016 hospice wage index.
We received nine comments on our
proposal to use the 2013 pre-floor, prereclassified hospital wage index to
derive the applicable wage index values
for the FY 2014 hospice wage index,
which are summarized below.
Comment: Some commenters
commented that is difficult to have the
hospice wage index dependent on the
hospital wage index due to the lack of
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data sometimes submitted by the
hospital on their cost report data and
the added responsibility for the hospice
to monitor the hospital wage index.
Some commented that the phase out of
the BNAF will leave the hospice
industry with an exceptionally
imprecise and un-validated wage index
with large geographic variations that
cannot be defended by local wage
pressures. Some commenters stated that
CMS should actively seek the
Congressional authority for granting
hospices wage index parity with
hospitals until an appropriate
alternative wage index approach for
hospices and other post-acute providers
can be developed. One commenter
asked CMS to re-evaluate the CBSA for
Montgomery County, Maryland as it is
considered a rural area at paid at a
lower rate than all the surrounding
counties.
Response: The pre-floor, prereclassified hospital wage index was
adopted in 1998 as the wage index from
which the hospice wage index is
derived by a committee of CMS (then
Health Care Financing Administration)
and industry representatives as part of
a negotiated rulemaking effort. The
Negotiated Rulemaking Committee
considered several wage index options:
(1) Continuing with Bureau of Labor
Statistics data; (2) using updated
hospital wage data; (3) using hospice
specific data; and (4) using data from
the physician payment system. The
Committee determined that the prefloor, pre-reclassified hospital wage
index was the best option for hospice.
Each hospice’s labor market area is
based on definitions of CBSAs issued by
the Office of Management and Budget
(OMB), not CMS. We note that section
3137(b) of the Affordable Care Act
requires CMS to submit to Congress a
report that includes a plan to reform the
hospital wage index system. The report
to Congress outlines the recent history
of analysis and proposed reform to the
Medicare wage index system. This
report was submitted by the Secretary
on April 11, 2012. The report can be
found at: https://www.cms.gov/Medicare/
Medicare-Fee-for-Service-Payment/
AcuteInpatientPPS/Wage-IndexReform.html. The latest information on
hospital wage index reform is discussed
in the ‘‘Hospital Inpatient Prospective
Payment Systems for Acute Care
Hospitals and the Long-Term Care
Hospital Prospective Payment System
and Fiscal Year 2013 Rates;’’ final rule,
published August 31, 2012 in the
Federal Register (77 FR 53660–53664).
We continue to believe that the prefloor, pre-reclassified hospital wage
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index, which is updated yearly and is
used by many other CMS payment
systems, is the most appropriate method
available to account for geographic
variances in labor costs for hospices.
Regarding about the commenters
concerns regarding the CBSA
classification of Montgomery County,
Maryland, it is important to note that
the cities and counties which make up
CBSAs are not determined by CMS, but
instead are established by the Office of
Management and Budget (OMB) and
have been adopted by Medicare through
notice and comment rule making. In our
August 4, 2005 FY 2006 Hospice Wage
Index final rule (70 FR 45130), we began
adopting the revised labor market area
definitions as discussed in the OMB
Bulletin No. 03–04 (June 6, 2003). In
addition, in the FY 2006 Hospice Wage
Index final rule (70 FR 45130), we
implemented a 1-year transition policy
using a 50/50 blend of the CBSA-based
wage index values and the MSA-based
wage index values for FY 2006. The
one-year transition policy ended on
September 30, 2006. For FY 2007 and
beyond, we have used CBSAs
exclusively to calculate wage index
values. Moreover, we also note that
under the hospice payment system,
payments are wage-adjusted based on
the location of the beneficiary.
Final Decision: After carefully
considering all of the comments that we
received on our proposal to use the 2013
pre-floor, pre-reclassified hospital wage
index to derive the applicable wage
index values for the FY 2014 hospice
wage index, we are finalizing the
proposal as discussed in the FY 2014
Hospice Wage Index and Payment Rate
Update proposed rule.
2. FY 2014 Hospice Wage Index With an
Additional 15 Percent Reduced Budget
Neutrality Adjustment Factor (BNAF)
This final rule will update the hospice
wage index values for FY 2014 using
2013 pre-floor, pre-reclassified hospital
wage index. As described in the August
8, 1997 Hospice Wage Index final rule
(62 FR 42860), the pre-floor and prereclassified hospital wage index is used
as the raw wage index for the hospice
benefit. These raw wage index values
are then subject to either a budget
neutrality adjustment or application of
the hospice floor to compute the
hospice wage index used to determine
payments to hospices. Pre-floor, prereclassified hospital wage index values
below 0.8 are adjusted by either: (1) The
hospice budget neutrality adjustment
factor (BNAF); or (2) the hospice floor
subject to a maximum wage index value
of 0.8; whichever results in the greater
value.
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The BNAF is calculated by computing
estimated payments using the most
recent, completed year of hospice
claims data. The units (days or hours)
from those claims are multiplied by the
updated hospice payment rates to
calculate estimated payments. For the
FY 2014 Hospice Wage Index final rule,
that means estimating payments for FY
2014 using units (days or hours) from
FY 2012 hospice claims data, and
applying the FY 2014 hospice payment
rates. The FY 2014 hospice wage index
values are then applied to the labor
portion of the payments. The procedure
is repeated using the same units from
the claims data and the same payment
rates, but using the 1983 Bureau of
Labor Statistics (BLS)-based wage index
instead of the updated raw pre-floor,
pre-reclassified hospital wage index
(note that both wage indices include
their respective floor adjustments). The
total payments are then compared, and
the adjustment required to make total
payments equal is computed; that
adjustment factor is the BNAF.
The August 6, 2009 FY 2010 Hospice
Wage Index final rule (74 FR 39384)
finalized a provision to phase out the
BNAF over 7 years, with a 10 percent
reduction in the BNAF in FY 2010, and
an additional 15 percent reduction in
each of the next 6 years, with complete
phase out in FY 2016. Once the BNAF
is completely phased out, the hospice
floor adjustment would simply consist
of increasing any wage index value less
than 0.8 by 15 percent, subject to a
maximum wage index value of 0.8.
Therefore, in accordance with the FY
2010 Hospice Wage final rule (74 FR
39384), the BNAF for FY 2014 will be
reduced by an additional 15 percent for
a total BNAF reduction of 70 percent (10
percent from FY 2010, an additional 15
percent from FY 2011, an additional 15
percent for FY 2012, an additional 15
percent for FY 2013 and an additional
15 percent in FY 2014).
The unreduced BNAF for FY 2014 is
0.061538 (or 6.1538 percent). A 70
percent reduction to the BNAF is
computed to be 0.018461 (or 1.8461
percent). For FY 2014, this is
mathematically equivalent to taking 30
percent of the unreduced BNAF value,
or multiplying 0.061538 by 0.30, which
equals 0.018461 (1.8461 percent). The
BNAF of 1.8461 percent reflects a 70
percent reduction in the BNAF. The 70
percent reduced BNAF (1.8461 percent)
was applied to the pre-floor, prereclassified hospital wage index values
of 0.8 or greater. The 10 percent reduced
BNAF for FY 2010 was 0.055598, based
on a full BNAF of 0.061775; the
additional 15 percent reduced BNAF FY
2011 (for a cumulative reduction of 25
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percent) was 0.045422, based on a full
BNAF of 0.060562; the additional 15
percent reduced BNAF for FY 2012 (for
a cumulative reduction of 40 percent)
was 0.035156, based on a full BNAF of
0.058593; the additional 15 percent
reduced BNAF for FY 2013 (for a
cumulative reduction of 55 percent) was
0.027197, based on a full BNAF of
0.060438; and the additional 15 percent
reduced BNAF for FY 2014 (for a
cumulative reduction of 70 percent) is
0.018461, based on a full BNAF of
0.061538.
Hospital wage index values which are
less than 0.8 are subject to the hospice
floor calculation. For example, if in FY
2013, County A had a pre-floor, prereclassified hospital wage index (raw
wage index) value of 0.3994, we would
perform the following calculations using
the budget-neutrality factor (which for
this example is an unreduced BNAF of
0.061538, less 70 percent, or 0.018461)
and the hospice floor to determine
County A’s hospice wage index: Prefloor, pre-reclassified hospital wage
index value below 0.8 multiplied by 1+
70 percent reduced BNAF: (0.3994 ×
1.018461 = 0.4068); Pre-floor, prereclassified hospital wage index value
below 0.8 multiplied by 1 + hospice
floor: (0.3994 × 1.15 = 0.4593). Based on
these calculations, County A’s hospice
wage index would be 0.4593.
An Addendum A and Addendum B,
with the FY 2014 wage index values for
rural and urban areas, will not be
published in the Federal Register. The
FY 2014 wage index values for rural
areas and urban areas are available via
the internet at: https://www.cms.gov/
Medicare/Medicare-Fee-for-ServicePayment/Hospice/. The FY
2014 hospice wage index set forth in
this final rule includes the BNAF
reduction and will be effective October
1, 2013 through September 30, 2014.
We received nine comments which
referenced the BNAF reduction, and are
summarized below.
Comment: Several commenters
continued to voice opposition to the
BNAF reduction and were concerned
about the impact of the elimination of
BNAF phase-out.
Response: The BNAF phase-out has
already been finalized for the remaining
years of the phase-out, as described in
the FY 2010 Hospice Wage Index final
rule (74 FR 39384). However, we are
sensitive to the issues raised by
commenters, especially the possible
effects of the BNAF reduction. Our
analysis reveals an overall growth in
number of hospices since the start of the
phase-out. We also note that the FY
2014 hospice wage index includes a
hospice floor calculation which benefits
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many rural providers. However, we will
continue to monitor for unintended
consequences associated with the BNAF
phase-out.
3. Hospice Payment Update Percentage
Section 4441(a) of the Balanced
Budget Act of 1997 (BBA) amended
section 1814(i)(1)(C)(ii)(VI) of the Act to
establish updates to hospice rates for
FYs 1998 through 2002. Hospice rates
were to be updated by a factor equal to
the market basket index, minus 1
percentage point. Payment rates for FYs
since 2002 have been updated according
to section 1814(i)(1)(C)(ii)(VII) of the
Act, which states that the update to the
payment rates for subsequent FYs must
be the market basket percentage for that
FY. The Act requires us to use the
inpatient hospital market basket to
determine the hospice payment rate
update. In addition, section 3401(g) of
the Affordable Care Act mandates that,
starting with FY 2013 (and in
subsequent FYs), the hospice payment
update percentage will be annually
reduced by changes in economy-wide
productivity as specified in section
1886(b)(3)(B)(xi)(II) of the Act which is
0.5 percentage point for FY 2014. In
addition, section 3401(g) of the
Affordable Care Act also mandates that
in FY 2013 through FY 2019, the
hospice payment update percentage will
be reduced by an additional 0.3
percentage point (although for FY 2014
to FY 2019, the potential 0.3 percentage
point reduction is subject to suspension
under conditions specified in section
1814(i)(1)(C)(v) of the Act). In FY 2014
Hospice Wage Index and Payment Rate
Update proposed rule (78 FR 27841), we
proposed 1.8 percent hospice payment
update percentage which was based on
a 2.5 percent estimated inpatient
hospital market basket update for FY
2014 reduced by a 0.4 percentage point
productivity adjustment and by 0.3
percentage point as mandated by the
Affordable Care Act. The final hospice
payment update percentage for FY 2014
is 1.7 percent and is based on the final
inpatient hospital market basket update
for FY 2014 of 2.5 percent reduced by
a 0.5 percentage point productivity
adjustment and by 0.3 percentage point
as mandated by the Affordable Care Act.
A detailed description of how the
inpatient hospital market basket is
derived is described in the FY 2014
IPPS Final Rule. Due to the
requirements at 1886(b)(3)(B)(xi)(II) and
1814(i)(1)(C)(v) of the Act, the inpatient
hospital market basket update for FY
2014 of 2.5 percent must be reduced by
a productivity adjustment as mandated
by Affordable Care Act (0.5 percentage
point for FY 2014). The inpatient
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hospital market basket for FY 2014 is
reduced further by a 0.3 percentage
point, as mandated by the Affordable
Care Act. In effect, the final hospice
payment update percentage for FY 2014
is 1.7 percent.
The labor portion of the hospice
payment rates are as follows: for
Routine Home Care, 68.71 percent; for
Continuous Home Care, 68.71 percent;
for General Inpatient Care, 64.01
percent; and for Respite Care, 54.13
percent. The non-labor portion of the
payment rates is as follows: for Routine
Home Care, 31.29 percent; for
Continuous Home Care, 31.29 percent;
for General Inpatient Care, 35.99
percent; and for Respite Care, 45.87
percent.
4. Final FY 2014 Hospice Payment Rates
Historically, the hospice rate update
has been published through a separate
administrative instruction issued
annually in the summer to provide
adequate time to implement system
change requirements; however, starting
in this FY 2014 rule and for subsequent
FYs, we proposed in the FY 2014
Hospice Wage Index and Payment Rate
Update proposed rule to use rulemaking
as the means to finalize hospice
payment rates. This change was
proposed to be consistent with the rate
update process in other Medicare
benefits, and would provide rate
information to hospices as quickly as, or
earlier than, when rates are published in
an administrative instruction.
There are four payment categories that
are distinguished by the location and
intensity of the services provided. The
base payments are adjusted for
geographic differences in wages by
multiplying the labor share, which
varies by category, of each base rate by
the applicable hospice wage index. A
hospice is paid the routine home care
rate for each day the beneficiary is
enrolled in hospice, unless the hospice
provides continuous home care,
inpatient respite care, or general
inpatient care. Continuous home care is
provided during a period of patient
crisis to maintain the patient at home,
inpatient respite care is short-term care
to allow the usual caregiver to rest, and
general inpatient care is to treat
symptoms that cannot be managed in
another setting.
The final FY 2014 payment rates will
be the FY 2013 payment rates, increased
by 1.7 percent, which is the final
hospice payment update percentage for
FY 2014 as discussed in section IV.C.3
above. The final FY 2014 hospice
payment rates will be effective for care
and services furnished on or after
October 1, 2013, through September 30,
2014.
TABLE 7—FINAL FY 2014 HOSPICE PAYMENT RATES UPDATED BY THE FINAL HOSPICE PAYMENT UPDATE PERCENTAGE
Code
651
652
655
656
FY 2013
Payment rates
Description
....
....
....
....
Routine Home Care .....................................................................................................
Continuous Home Care Full Rate = 24 hours of care = 37.95 hourly rate .................
Inpatient Respite Care .................................................................................................
General Inpatient Care .................................................................................................
The Congress required in sections
1814(i)(5)(A) through (C) of the Act that
hospices begin submitting quality data,
based on measures to be specified by the
Secretary. Beginning in FY 2014,
hospices which fail to report quality
data will have their market basket
$153.45
895.56
158.72
682.59
Multiply by the
FY 2014 final
hospice payment update
of 1.7 percent
×
×
×
×
1.017
1.017
1.017
1.017
FY 2014 final
payment rate
$156.06
910.78
161.42
694.19
required to begin collecting quality data
in October 2012, and submit that quality
data in 2013. Hospices failing to report
quality data in 2013 will have their
market basket update reduced by 2
percentage points in FY 2014.
update reduced by 2 percentage points.
In the August 4, 2011 FY 2012 Hospice
Wage Index final rule (76 FR 47320
through 47324), we implemented a
Hospice Quality Reporting Program
(HQRP) as required by section 3004 of
the Affordable Care Act. Hospices were
TABLE 8—FINAL FY 2014 HOSPICE PAYMENT RATES UPDATED BY THE FINAL HOSPICE PAYMENT UPDATE PERCENTAGE
FOR HOSPICES THAT DO NOT SUBMIT THE REQUIRED QUALITY DATA
Code
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651
652
655
656
......................
......................
......................
......................
Routine Home care ....................................................................................
Continuous Home Care Full Rate = 24 hours of care = 37.20 hourly rate
Inpatient Respite Care ...............................................................................
General Inpatient Care ...............................................................................
A Change Request with the finalized
FY 2014 hospice payment rates, a
finalized FY 2014 hospice wage index,
the FY 2014 PRICER, and the hospice
cap amount for the cap year ending
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FY 2013
Payment rates
Description
17:25 Aug 06, 2013
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October 31, 2013 will continue to be
issued in the summer.
We received two comments on our
proposal to use rulemaking as the means
to finalize hospice payment rates, which
are summarized below.
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$153.45
895.56
158.72
682.59
Multiply by the
FY 2014 hospice payment
update percentage of 1.7
percent minus
2 percentage
points (¥0.2)
×
×
×
×
0.997
0.997
0.997
0.997
FY 2014
Payment rate
$152.99
892.87
158.24
680.54
Comment: Commenters were
supportive of CMS’ proposal to use
rulemaking as the means to finalize
hospice payment rates followed by a
change request with the finalized
hospice payment rates, a finalized
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hospice wage index, the PRICER for FY
2014.
Response: We thank you for your
support. We will finalize hospice
payment rates as stated in the FY 2014
Hospice Wage Index and Payment Rate
Update proposed rule (78 FR 27841).
Comment: We also received several
additional comments that expressed
concern that hospice industry is being
over regulated, while reimbursement is
decreasing and examples given include
the face-to-face regulation, data
collection efforts, and quality initiatives.
Several commenters are concerned that
these regulations not only increase
financial burden for hospice industry
but also pull hospices away from patient
care and keep hospice providers in the
office to perform administrative duty to
comply with regulations. Some
commenters described a shortage of staff
in some areas of the country, especially
small hospices and in rural areas, and
stated that the staff travel hours in rural
areas to examine the patient, which is
a burden itself because of travel
distance. Several commenters stated
that reimbursement is decreasing
because of the continuing rate cuts
resulting from the elimination of the
budget neutrality adjustment factor, the
cuts resulting from the productivity
adjustment factor, and further rate
reduction resulting from sequestration.
A commenter stated that the proposed
hospice payment update of 1.8 percent
for 2014, coupled with other cuts is
devastating.
Response: We appreciate comments
regarding sequestration cut, but it is
outside the scope of this rule. As stated
in FY 2013 Hospice Wage Index notice
(77 FR 44245), section 3401(g) of the
Affordable Care Act mandates that
starting with FY 2013 (and in
subsequent FYs), the market basket
percentage update under the hospice
payment system as described in section
1814(i)(1)(C)(ii)(VII) or section
1814(i)(1)(C)(iii) of the Act will be
annually reduced by changes in
economy-wide productivity as set out at
section 1886(b)(3)(B)(xi)(II) of the Act.
We do not have authority to change the
application of economy-wide
productivity adjustment as it is required
by the statute. We are sensitive to
concerns about hospices being
overregulated and concerns expressed
from rural hospices that the additional
time and distance required to visit a
rural patient adds significantly to their
costs. We do not have the authority to
change the hospice rates beyond the
limits set out in the statute, but will
consider the costs of rural providers in
the context of broader hospice payment
system reform. We will continue to
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monitor the impact of our regulations
for any unintended consequences. As
described in the Regulatory Impact
Analysis (Section, VI), we note that the
overall impact of this final rule is an
estimated net increase in Federal
payments to hospices of $160 million,
or 1.0 percent, for FY 2014.
Final Decision: As stated in the FY
2014 Hospice Wage Index and Payment
Rate Update proposed rule, we
proposed to finalize hospice payment
rates through rulemaking and we are
finalizing this policy as proposed. A
change request with the finalized FY
2014 hospice payment rates, a finalized
FY 2014 hospice wage index, the FY
2014 PRICER, and the hospice cap year
ending October 31, 2013 will continue
to be issued in the summer.
D. Update on Hospice Payment Reform
and Data Collection
In 2010, the Congress amended
section 1814(i)(6) of the Act with
section 3132(a) of the Affordable Care
Act. The amendment authorized the
Secretary to collect additional data and
information determined appropriate to
revise payments for hospice care and for
other purposes. The types of data and
information described in the Act would
capture resource utilization and other
measures of cost, which can be collected
on claims, cost reports, and possibly
other mechanisms determined to be
appropriate. The data collected may be
used to revise the methodology for
determining the payment rates for
routine home care, and other services
included in hospice care, no earlier than
October 1, 2013 as described in section
1814(i)(6)(D) of the Act. In addition, we
are required to consult with hospice
programs and the Medicare Payment
Advisory Commission (MedPAC)
regarding additional data collection and
payment revision options.
The proposed rule contained three
subsections which updated the public
or discussed different aspects of hospice
payment reform; there were no
proposals in any of these three
subsections.
1. Update on Reform Options
Our hospice contractor, Abt
Associates, continues to conduct
research and analyses, to identify
potential data collection needs, and to
research and develop hospice payment
model options. To date, we completed
an environmental scan; a draft analytic
plan; and convened technical advisory
panel meetings under the initial
contract with Abt in 2010. We are
continuing with these efforts under a
contract awarded in September 2011. In
June 2012, we convened stakeholder
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48271
meetings where research findings were
presented on potential payment system
vulnerabilities; utilization of the
Medicare Hospice Benefit, including
general inpatient care use during the
period the beneficiary is enrolled in
hospice care; analysis of hospice cost
reports; and the effects of the face-toface encounter requirement. These and
other findings are described in the Abt
Hospice Study Technical Report, which
is available on the CMS Hospice Center
Web page, at https://www.cms.gov/
Center/Provider-Type/HospiceCenter.html.
Additionally, we continue to conduct
analyses of various payment reform
model options under consideration.
These models include a U-shaped
model of resource use, which MedPAC
recommended that we adopt, as
originally described in Chapter 6 of its
March, 2009 report entitled ‘‘Report to
the Congress: Medicare Payment Policy’’
(available online at: https://
www.medpac.gov/chapters/
Mar09_Ch06.pdf). The report noted that
the constancy of the per diem payment
over the course of a hospice stay is
misaligned with a hospice’s costs during
the stay. A hospice’s costs typically
follow a U-shaped curve, with higher
costs at the beginning and end of a stay,
and lower costs in the middle of the
stay. This cost curve reflects hospices’
higher service intensity at the time of
the patient’s admission and the time
surrounding the patient’s death
(MedPAC, page 358). Payment under a
U-shaped model would be higher at the
beginning and end of a hospice stay and
lower in the middle portion of the stay.
Analysis conducted by Abt Associates
found that very short hospice stays have
a flatter curve than the U-shaped curve
seen for longer stays and that average
hospice costs are much higher. These
short stays are less U-shaped because
there is not a lower-cost middle period
between the time of admission and the
time of death. As such, we are also
considering a tiered approach, with
payment tiers based on the length of
stay. For example, payment for stays of
5 days or less, which occurred for about
25 percent of hospice beneficiaries in
2011, could be made under a per diem
system that accounts for the higher
hospice costs, with no variation in the
rate based on length of stay as would
occur under a U-shaped model.
Payment for longer stays, where costs
follow more of a U-shape, could be
made under a tier based on the Ushaped payment model, where the per
diem amount fluctuates depending
upon whether the days billed are at the
beginning, middle, or end of the stay.
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Another option is to analyze whether
a short-stay add-on payment, similar to
the home health Low Utilization
Payment Amount (LUPA) add-on,
would improve payment accuracy if we
retain the current per diem system. The
LUPA add-on is made for home health
patients who require four or fewer visits
during the 60-day episode. These home
health episodes are paid based on the
visits actually furnished during the
episode. For LUPA episodes that occur
as the only episode or the first episode
in a sequence of adjacent home health
episodes for a given beneficiary, an
increased payment is made to account
for the front-loading of costs (see
https://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/downloads/
HomeHlthProspaymt.pdf for more
information).
Finally, as we collect more accurate
diagnosis data, including data on related
conditions, we will also evaluate
whether case-mix should play a role in
determining payments.
a. Rebasing the Routine Home Care
(RHC) Rate
In the proposed rule, we updated our
review of the hospice RHC rate, but did
not include any proposals to rebase the
rate. Rebasing the RHC rate involves
using the existing components that
make up the rate, and recalculating
based on more current data. RHC is the
basic level of care under the Hospice
benefit, where a beneficiary receives
hospice care, but remains at home. With
this level of care, hospice providers are
reimbursed per day regardless of the
volume or intensity of services provided
to a beneficiary on any given day. It is
anticipated that there would be days
when a beneficiary does not require any
services, as well as days when a
beneficiary requires several visits from
the hospice provider.
When the hospice benefit was created
in 1983, the RHC base payment rate was
set using nine different components of
cost from a relatively small set of
hospices (n = 26) that were participating
in a CMS hospice demonstration, as
described in the December 16, 1983
Hospice final rule (48 FR 56008). The
nine cost components were: nursing
care ($16.25); home health aide ($12.74);
social services/therapy ($3.23); home
respite ($1.46); interdisciplinary group
($2.78); drugs ($1.18); supplies ($4.49);
equipment ($1.13); and outpatient
hospital therapies ($2.99). The sum of
all the components’ costs equaled the
base payment rate for RHC as stated in
that 1983 hospice final rule. The
original RHC rate was set at $46.25. In
addition to RHC, we also established
three other levels of care for hospice
care from data obtained from the
Medicare hospice demonstration
project: Continuous Home Care (CHC),
Inpatient Respite Care (IRC) and General
Inpatient Care (GIP).
It is CMS’ intent to ensure that
reimbursement rates under the Hospice
benefit align as closely as possible with
the average costs hospices incur when
efficiently providing covered services to
beneficiaries. As we continue to gather
and analyze more data for payment
reform, we have found evidence of a
potential misalignment between the
current RHC payment rate and the cost
of providing RHC. One potential option
to address this misalignment could be to
rebase the hospice RHC rate, though we
did not propose to do so in the proposed
rule, so that the cost categories
established in the rate reflect the
changes in the utilization of hospice
services provided for palliation and
management of terminally ill patients.
However, we are still evaluating data
and did not propose any changes to
address the misalignment.
At this time, we do not have the data
to support rebasing six of the nine cost
components described in the 1983 final
rule. Information on the utilization of
drugs, supplies, and equipment is not
available from hospice claims data, and
the corresponding information that is
available from cost reports, such as
outpatient hospital therapies, is not
sufficiently detailed to allow for
rebasing. One approach to consider in
more closely aligning RHC payments
with costs is to rebase the three clinical
service components (nursing, home
health aide, social services/therapy) that
currently comprise 69.7 percent of the
RHC rate by calculating the average cost
per day, weighted by the number of
RHC days, for each of the three
components using FY 2011 cost report
data matched to FY 2011 claims data.
As part of rebasing the RHC rate we
would then inflate the 1983 cost per day
for each of the six remaining
components by a factor of 3.1704, which
corresponds to the market basket
increases between 1983 and 2011.8 We
note that our cost report analysis thus
far found that drug costs over the years
have declined, and the other non-labor
components are plateauing. A detailed
methodology for rebasing the clinical
service components of the RHC rate can
be found in the Abt Hospice Study
Technical Report which was published
shortly after displaying the proposed
rule, at https://www.cms.gov/Center/
Provider-Type/Hospice-Center.html.
Using the methodology described
above, the rebased amount for FY 2011
would be $130.54 as described in Table
9 below.
TABLE 9—COMPARISON OF RHC RATE COST COMPONENTS FROM 1983 TO FY 2011
1983 Final
rule cost per
day
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RHC components
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
1.18
4.49
1.13
2.99
46.25
Source: 1983 Final Rule and FY 2011 hospice cost report and claims data.
8 The original RHC rate in 1983 was $46.25. The
FY 2011 rate for RHC was $146.63. $146.63/46.25
= 3.1704.
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Inflation
factor
N/A
N/A
N/A
× 3.1704
× 3.1704
× 3.1704
× 3.1704
× 3.1704
× 3.1704
....................
FY 2011
Cost per
day
$56.54
19.24
10.29
4.63
8.81
3.74
14.23
3.58
9.48
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48273
Note(s): The costs per day for the clinical services components (nursing care, home health aide and social services/therapy) were calculated
based on the cost per minute for each discipline using cost report data multiplied by the RHC minutes for each discipline per RHC day from
claims data to compute the cost of a discipline per RHC day. The average cost per day across all hospices in our sample was weighted by the
number of RHC days. Of the 2,717 FY 2011 hospice cost reports for freestanding and facility-based hospices that were matched to FY 2011
claims data, we excluded: (1) Cost reports with period less than 10 months or greater than 14 months; (2) cost reports with missing information
or negative reported values for total costs or payments; (3) providers in the highest and lowest percentile (1% and 99%) in costs per days across
all levels of care; (4) the top and bottom 5% of provider margin; and (5) providers were excluded if the log payment to cost ratio was greater than
the 90th or less than the 10th percentile of this value across all providers plus or minus 1.5 times the range between the 10th and 90th percentiles of this log ratio. The number of hospices remaining in our sample was 2,140 representing 73.1 percent of RHC days in 2011.
For example, if we were to apply the
rebased amounts for the clinical services
components of RHC to FY 2014, we
would inflate the FY 2011 rebased
amount to FY 2013 levels. We first
inflated the FY 2011 rebased rate by full
hospital market basket of 3.0 percent for
FY 2012. The FY 2012 rebased rate
would be $134.46 ($130.54 × 1.03 =
$134.46). We then inflated the FY 2012
rebased rate by full hospital market
basket of 2.6 percent for FY 2013. The
FY 2013 rebased rate would be $137.96
($134.46 × 1.026 = $137.96). Finally, we
inflated the rebased FY 2013 rate
($137.96) by applying the proposed
hospice payment update percentage of
1.8 percent to calculate a FY 2014
rebased RHC rate. Therefore, the FY
2014 rebased rate would be $140.44, a
10.1 percent reduction in the FY 2014
proposed RHC payment rate of $156.21,
or an estimated reduction in payments
to hospices of $1.6 billion in FY 2014.
Rebasing the clinical service
components of the RHC payment is one
of several approaches to hospice
payment reform that CMS could
consider for revising the RHC payment
rate. As outlined in the Affordable Care
Act, hospice payment reform must be
done in a budget neutral manner. As
rebasing is considered part of hospice
payment reform, any savings achieved
through the reduction of the RHC rate
would need to be redistributed in a
budget neutral manner.
b. Site of Service Adjustment for
Hospice Patients in Nursing Facilities.
As part of future hospice payment
reform, we are considering an OIG
recommendation to reduce payments to
Medicare hospices for beneficiaries in
nursing facilities who are receiving
hospice care. The OIG’s July 2011 report
entitled ‘‘Medicare Hospices that Focus
on Nursing Facility Residents,’’
(available at https://oig.hhs.gov/oei/
reports/oei-02-10-00070.pdf) studied
hospice patients in nursing facilities.
This report noted the growth of hospice
services provided to beneficiaries in
nursing facilities, and discussed
hospices that have a high percentage of
their beneficiaries in nursing facilities.
The OIG’s report noted that the current
payment structure provides incentives
for hospices to seek out beneficiaries in
nursing facilities, as these beneficiaries
often receive longer but less complex
care. The OIG noted that unlike private
homes, nursing facilities are staffed with
professional caregivers and are often
paid by third-party payers, such as
Medicaid. These facilities are required
to provide personal care services, which
are similar to hospice aide services that
are paid for under the hospice benefit.
To lessen this incentive, the OIG
recommended that we reduce Medicare
payments for hospice care provided in
nursing facilities.
In addition, the March 2012 Medicare
Payment Advisory Commission
(MedPAC) report entitled ‘‘Report to
Congress: Medicare Payment Policy’’
noted that hospices with a higher share
of their patients in nursing facilities
have margins as high as 13.8 percent
(pages 302 and 303). MedPAC attributed
these higher margins to possible
efficiencies in the nursing home setting
(multiple patients in a single setting,
reduced driving time and mileage), and
to reduced workload due to an overlap
in aide services and supplies provided
by the nursing facility.
In response to both MedPAC’s and
OIG’s concerns about possible
duplication of aide services provided
both by the hospice and the nursing
facility, in the proposed rule we
discussed an analysis of the number and
length of aide visits per day using 2011
hospice claims data. Table 10 below
describes the number and length of aide
visits for RHC beneficiaries at home
(including patients in an assisted living
facility) compared to RHC beneficiaries
in a long term care nursing facility (NF)
or skilled nursing facility (SNF).
TABLE 10—HOSPICE ROUTINE HOME CARE AIDE SERVICES, CY 2011
Sites of service
Home Q5001/2
Number of beneficiaries ...................................................................
Total days ........................................................................................
Total visits ........................................................................................
Total minutes ...................................................................................
Visits per beneficiary .......................................................................
Minutes per visit ...............................................................................
Total visits/day .................................................................................
Total minutes/day ............................................................................
769,640
58,637,171
16,625,635
1,223,254,095
21.6
73.6
0.28
20.86
Difference
NF/SNF Q5003/4
302,004
22,946,972
8,501,366
584,825,520
28.1
68.8
0.37
25.49
NF/SNR–Home
%
(467,636)
(35,690,199)
(8,124,269)
(638,428,575)
6.5
(4.8)
0.09
4.62
............................
............................
............................
............................
30.3
6.5
30.7
22.2
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Source: Abt Associates Hospice Claims Data File, CY 2011.
Table 10 demonstrates that hospice
patients in a NF/SNF receive more visits
than patients at home, though the length
of those visits is shorter. Average
minutes per day shows that RHC
patients in a NF/SNF had hospice aide
services of longer duration (25.49
minutes) than RHC patients at home
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(20.86 minutes). The Medicare
Conditions of Participation (CoPs)
require that hospices provide services at
the same level and to the same extent as
those services would be provided if the
NF/SNF resident were in his or her
home. Hospices provide aide services to
beneficiaries at home depending on the
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beneficiaries’ needs. It seems reasonable
to expect that a beneficiary who has a
paid caregiver (that is, a NF/SNF aide)
does not need as many services from the
hospice aide, because those services are
being provided by the paid caregiver. As
described in the June 5, 2008 Hospice
Conditions of Participation final rule (73
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FR 32095), ‘‘[h]ospice care is meant to
supplement the care provided by the
patient’s caregiver.’’ Given the presence
of the paid caregiver in the NF/SNF, we
would expect that on average, there
would be fewer hospice aide services
provided to hospice patients in a NF/
SNF than to hospice patients at home.
It is not clear why hospice patients in
nursing facilities are receiving more
minutes per day of aide services than
hospice patients at home. We used
regression analysis to control for age,
gender, diagnosis, length of stay, and
provider characteristics (ownership
status, base, size, age of hospice,
geographic location) when analyzing the
visit data. However, we still found that
significantly more aide services were
provided to NF/SNF patients than to
patients at home, even after controlling
for patient and provider characteristics.
The June 5, 2008 Hospice Conditions
of Participation final rule (73 FR 32088)
preamble details the requirements
related to aide services provided to
hospice patients residing in a nursing
facility. These requirements can also be
found at § 418.112(c)(4) through (5). The
CoPs require a written agreement
between the hospice and NF/SNF,
which specifies that the NF/SNF should
continue to provide the aide services
that are provided prior to the hospice
election, to meet the patient’s needs at
that same level of care as if the patient
were at home. These services include
providing 24 hour room and board care,
meeting the patient’s personal care
needs, and to the degree permitted by
State law, administering medications or
therapies. There should be no reduction
of NF/SNF aide services to a patient in
anticipation of a future hospice election,
or once the patient (or his/her
representative) elects the hospice
benefit. As such, hospice patients in
nursing facilities should have much, if
not most, of their need for aide services
provided by the facility’s aide. As stated
previously, we would expect that, on
average, the hospice aide would be
providing fewer services to nursing
facility patients than to patients at
home.
Table 10 suggests that the hospice
aide may be replacing the facility aide,
rather than supplementing or
augmenting the care of the facility aide.
Or, as the OIG and MedPAC identified,
there could be an overlap in aide
services when a hospice beneficiary is
in a NF/SNF. It would not be
appropriate for the Medicare Hospice
Benefit to subsidize the nursing home
benefit by providing aide services that
the facility aide should provide. Section
1862(a)(1)(C) of the Social Security Act
(the Act) forbids payment for any items
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or services which are not reasonable and
necessary for the palliation and
management of the terminal illness.
Services which are not needed, or
which are duplicative of those to be
provided by the facility aide, would not
be reasonable and necessary.
In the proposed rule, we did not
propose to make a site of service
adjustment to reduce payments for RHC
patients in a nursing facility. Any
reform option considering reduced
payments for RHC care provided to
hospice patients in a NF or SNF should
not result in a reduction in the services
that hospice patients in NFs or SNFs
receive, but would instead be a shifting
of who provides those aide services;
some of the services currently provided
by the hospice aide would be provided
by the facility aide as expected. As such,
we do not expect that the quality of care
to hospice patients in a NF/SNF would
be diminished. If such a policy were to
be finalized and implemented, it would
be made in a budget neutral manner as
required by the Affordable Care Act. In
addition, we would monitor for any
unintended consequences.
2. Reform Research Findings
The proposed rule also included a
discussion of a number of analyses we
conducted to better understand hospice
utilization and trends, to identify
vulnerabilities in the payment system,
and to develop and test models that
would more accurately match hospice
resource use with Medicare payments.
We posted the Abt Hospice Study
Technical Report on hospice payment
reform on our hospice center Web page,
located at: https://www.cms.gov/Center/
Provider-Type/Hospice-Center.html.
The report summarizes research
findings related to resource use and
payment system vulnerabilities.
The report also includes a discussion
of hospice cost report analyses. Overall,
the total cost per election period has not
significantly increased from 2007 to
2010, in real dollars. Inpatient costs
constitute about 14 percent of hospice
costs across freestanding hospice
providers that reported inpatient costs.
About one-third of providers reported
no inpatient costs. It appeared that some
providers with no inpatient costs were
substituting continuous home care
(CHC) for GIP, based on analysis of the
proportion of CHC days. Visiting
services (for example, direct labor costs
for nurses, aides, social workers,
counselors, and therapists) account for
about two-thirds of hospice costs, and
have trended upward from 2004 to
2010. Nursing care, hospice aides, and
medical social services comprise 90
percent of visiting service costs.
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Other hospice service costs include
non-labor costs such as drugs, durable
medical equipment (DME), supplies,
imaging, patient transportation, and
outpatient services. These types of
services represent about 20 to 25
percent of total hospice costs. Drugs,
DME, and supplies account for 90
percent of these other hospice services
costs. Drug costs have trended
downward over time, while medical
supply costs have remained steady.
Finally, in examining non-reimbursable
costs, we found that 26 percent of
providers in 2010 showed no
bereavement costs on their cost report,
even though bereavement services are
required by statute; it is unclear if
bereavement services were not provided
or if bereavement costs were not
correctly reported.
The report also describes an analysis
of GIP utilization. In 2010 through 2011,
a quarter of all hospice beneficiaries had
at least one GIP stay, with a quarter of
those stays associated with cancer
diagnoses. While most GIP stays were 2
days long, the average GIP length of stay
was 5.66 days, reflecting a small number
of extremely long GIP stays. Sixty-five
percent of GIP stays were provided in a
hospice inpatient unit. Almost 80
percent of hospices provided at least
one GIP day in 2010 through 2011.
Hospices that provided GIP tended to be
older and larger.
The Abt Hospice Study Technical
Report also provides descriptive
statistics for all beneficiaries and for 3
major sites of routine home care
services. It includes visit data findings,
including visits per day, visits per
beneficiary, minutes per day, and
minutes per beneficiary for key
disciplines reported on hospice claims.
Additionally, there are several figures
which depict the U-shaped curve for
key personnel by length of stay. The
curves show that resource use tends to
follow a U-shaped curve, but one which
is higher at the beginning rather than at
the end of the hospice stay. There was
little evidence that strong differences in
the U-shape exist across most subgroups
(for example, freestanding vs. providerbased, ownership status, patient
diagnosis).
For more detailed information on
these findings, and a description of the
methods used, see the Abt Hospice
Study Technical Report, which is
posted on the hospice center Web page
(https://www.cms.gov/Center/ProviderType/Hospice-Center.html). We have
also posted a review of pertinent
hospice literature as of December 2012
on the hospice center Web page. This
should be considered an evolving
document, as Abt Associates updates
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the review periodically. We encourage
interested stakeholders to review this
update on our progress. We will
continue to collaborate with other
federal experts regarding hospice
payment reform research efforts and to
update stakeholders on our progress on
hospice payment reform.
3. Additional Data Collection
Over the past several years, MedPAC,
the Government Accountability Office
(GAO), and the HHS Office of Inspector
General (OIG) have also recommended
that we collect more comprehensive
data in order to better understand the
utilization of the Medicare Hospice
Benefit. In the proposed rule, we noted
that in December 2012 we posted a
document to our Hospice Center Web
page (https://www.cms.gov/Center/
Provider-Type/Hospice-Center.html)
describing additional data collection
which we are considering, and noting
that cost report revisions are
forthcoming. We received 65 comments
about the claims data collection items
under consideration, which are briefly
summarized below.
• Line item visit data, including
length of visit in 15-minute increments,
for hospice chaplains and counselors
providing care to hospice beneficiaries.
Commenters were supportive, but
suggested we include phone calls by
chaplains and counselors, and allow
reporting of chaplain time spent
officiating or attending beneficiary
funerals, as this is part of their service
to families. A few suggested that we
have a separate category for
Bereavement Counseling to
acknowledge this requirement even if it
is not subject to reimbursement. Several
suggested we define ‘‘other counselors.’’
• Line item visit data, including
length of visits in 15-minute increments,
for hospice staff providing care to
hospice patients receiving GIP in a
hospital or nursing facility, but not for
hospice patients receiving GIP in a
hospice facility. Our suggestion to
collect GIP visit data did not include
visits by non-hospice staff, and was
focused on patients in a hospital or
nursing facility only. Therefore, GIP
visits to hospice patients in hospice
inpatient facilities continue to be
reported as weekly totals, without
including the length of visits.
Commenters were generally supportive,
provided the visits were for hospice
staff only. Several comments noted that
this would be no more difficult than
what already occurs when recording
visits to patients’ homes.
• The National Provider Identifier
(NPI) of facilities where hospice patients
are receiving care. Most commenters
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noted that it would not be difficult to
get this information and enter it into
their systems. A few commenters noted
that sometimes patients are in more
than one facility type during a claim
period, but that there is only space for
one NPI on the claim.
• Post-mortem visits on the calendar
day of death. Commenters suggested we
collect visit data for various timeframes
after the time of death, rather than the
calendar day of death, since many
deaths occur late at night. They
suggested we clarify what we mean by
time of death (time death actually
occurs, or time the death is
pronounced). Several commenters
suggested we gather post-mortem visit
data regardless of level of care or site of
service.
• Any durable medical equipment
(DME) provided by the hospice. Some
commenters indicated that this would
be difficult to collect and record on
claims. Many indicated that DME
suppliers bill them monthly, and
waiting for the DME invoice would
cause a delay in submission of their
claims. They also noted that it would
take a great deal of lead time to set this
up with suppliers and software vendors
to track DME at the patient level. A few
suggested that we use aggregate data on
DME costs from the cost reports instead.
• Non-routine supplies provided by
the hospice. Most commenters indicated
that this would be difficult to collect
and record on claims. A number of
commenters wrote that their software
does not accommodate such reporting,
and that it would create an additional
burden on clinical staff to track these
items. Several mentioned that it would
take some lead time to modify existing
systems to enable hospices to track and
report this information accurately. A
few suggested we use aggregate data on
non-routine supplies from the cost
reports instead.
• Drugs (injectable, non-injectable,
and over-the-counter) provided by the
hospice. Most commenters indicated
that this would be difficult to collect
and record on claims. Several asked if
injectable drugs include infusion
pumps, which is considered DME.
Several commenters noted that the
hospice staff person is not always the
person administering drugs, making
tracking more complicated; they
suggested focusing on the fills, rather
than drugs administered. Some wrote
that hospices get their drugs from
multiple pharmacies, making reporting
more difficult due to inconsistencies in
pharmacy billing. Others wrote that
their data systems are not able to track
drugs by patient, and suggested that we
use aggregate data from the cost reports
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instead. Some noted that they purchase
some drugs in larger quantities, making
reporting at the patient level more
complicated. A few noted that this
could be done, but said that hospices
would need lead time to prepare
systems to track and report at the
patient level. One suggested that we
specify what cost structure drug charges
should be based upon, such as average
wholesale price plus a percentage.
In summary, commenters were largely
supportive of our suggestions to collect
additional visit and NPI data on claims.
Many suggested collecting data on DME,
supplies, and drugs from the cost
reports, rather than at the patient level.
Several commenters reminded us that
their primary focus is patient care, and
were concerned about the cost of such
data collection. We appreciate the
comments submitted, and will consider
this input as we move forward towards
implementing any new data collection
for hospices. We issued Change Request
8358 on Friday, July 26, 2013 detailing
the new data collection requirements.
Section 3132(a)(1)(C) of the
Affordable Care Act also authorizes us
to collect more data on hospice cost
reports. The revisions to the hospice
cost report and its associated
instructions are described in detail in a
revision to the information collection
request currently approved under OMB
control number 0938–0758. As required
by the Paperwork Reduction Act, we
published the both 60-day and 30-day
notices with comment periods in the
Federal Register on April 29, 2013 (78
FR 25089).
The proposed rule did not solicit
comments on our hospice payment
reform updates and discussions, but we
received 54 comments on this section.
We thank the commenters for their
input and we will consider the
comments received as we move forward
with hospice payment reform.
E. Technical and Clarifying Regulations
Text Change
We proposed to incorporate the
following technical change to correct an
erroneous cross reference in our
regulations text.
Administrative Appeals (§ 418.311)
A hospice that does not believe its
payments have been properly
determined may request a review from
the intermediary or from the Provider
Reimbursement Review Board (PRRB),
depending on the amount in
controversy. Section 418.311 details the
procedures for appealing a payment
decision and also refers to 42 CFR part
405, subpart R. The rationale for this
appeals process was explained in the
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August 22, 1983 Hospice proposed rule
(48 FR 38146) and finalized in the
December 16, 1983 Hospice final rule
(48 FR 56008). Hospices are permitted
to appeal computation of the payment
limit or the amount due to the hospice
to the PRRB if the amount in
controversy is $10,000 or more.
We made a technical correction in
§ 418.311 to correct an erroneous
reference to § 405.1874. The published
reference to § 405.1874 does not exist
and was a typographic error. We are
correcting this error by changing the
referenced § 405.1874 to § 405.1875—
Administrator review. Section 405.1875
allows for the Administrator, at his or
her discretion, to immediately review
any decision of the Board as described
in the August 22, 1983 proposed and
December 16, 1983 final rules (48 FR
38159, and 48 FR 56019, respectively).
We received no comments on this
proposed technical correction, and are
implementing the correction as
proposed.
V. Collection of Information
Requirements
Under the Paperwork Reduction Act
of 1995, we are required to provide 60day notice in the Federal Register and
solicit public comment before a
collection of information requirement is
submitted to the Office of Management
and Budget (OMB) for review and
approval. In order to fairly evaluate
whether an information collection
should be approved by OMB, section
3506(c)(2)(A) of the Paperwork
Reduction Act of 1995 requires that we
solicit comment on the following issues:
• The need for the information
collection and its usefulness in carrying
out the proper functions of our agency.
• The accuracy of our estimate of the
information collection burden.
• The quality, utility, and clarity of
the information to be collected.
• Recommendations to minimize the
information collection burden on the
affected public, including automated
collection techniques.
We solicited public comment on each
of these issues for this section of this
document that contains information
collection requirements (ICRs).
Section 1814(i)(5)(C) of the Act
requires that each hospice submit data
to the Secretary on quality measures
specified by the Secretary. Such data
must be submitted in a form and
manner, and at a time specified by the
Secretary. Under section
1814(i)(5)(D)(iii) of the Act, the
Secretary must publish selected
measures that will be applicable with
respect to FY 2014 not later than
October 1, 2012. In implementing the
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Hospice quality reporting program, we
seek to collect measure information
with as little burden to the providers as
possible and which reflects the full
spectrum of quality performance.
We proposed and will implement a
Hospice Experience of Care Survey to
reflect the patients’ families’ and
friends’ perspectives of care in hospices.
The 60-day notice for the field test of
the survey was published on April 4,
2013 (78 FR 20323) under CMS–10475
(OCN 0938-New). While we set out the
requirements and burden estimates for
the field study, it is too early to set out
the requirements and burden estimates
for the national implementation of the
survey. We anticipate having the final
survey instrument in 2014 and setting
out the collection of information
requirements and burden estimates in
the proposed rule for CY 2015. We will
implement the survey in 2015.
In this final rule we are requiring
implementation of a hospice patientlevel item set to be used by all hospices
to collect and submit standardized data
on each patient admitted to hospice.
This Hospice Item Set will be used to
support the standardized collection of
the requisite data elements to calculate
quality measures. Hospices will be
required to complete and submit an
admission HIS and a discharge HIS on
all patients admitted to hospice starting
July 1, 2014 for FY 2016 APU
determination. The admission and
discharge HIS will collect the
standardized data elements needed to
calculate 7 NQF endorsed measures for
hospice.
Using 2011 Medicare claims data we
have estimated that there will be
approximately 1,089,719 admissions
across all hospices per year and
therefore, we expect that there should
be 1,089,719 Hospice Item Sets
(consisting of one admission and one
discharge item set per patient),
submitted across all hospices yearly.
There were 3,742 certified hospices in
the U.S. as of October 1, 2012; we
estimate that each individual hospice
will submit on average 291 Hospice
Item Sets annually or 24 Hospice Items
Sets per month.
The Hospice Item Set consists of both
an admission and a discharge data
collection. As noted above, we estimate
that there will be 1,089,719 hospice
admissions across all hospices per year.
Therefore, we expect there to be
2,179,438 Hospice Item Set
submissions, (both admission and
discharge data) submitted across all
hospices annually or 181,620 across all
hospices monthly. We further estimate
that there will be 582 Hospice Item Set
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submissions by each hospice annually
or 49 submissions monthly.
For the Admission Hospice Item Set,
we estimate that it will take 14 minutes
of time by a clinician such as a
Registered Nurse at an hourly wage of
$33.23 to abstract data for Admission
Hospice Item Set. This will cost the
hospice approximately $7.75 for each
admission assessment.9 We further
estimate that it will take 5 minutes of
time by clerical or administrative staff
person such as a medical data entry
clerk or medical secretary at an hourly
wage of $15.59 to upload the Hospice
Item Set data into the CMS system. This
will cost the hospice approximately
$1.30 per assessment.10 For the
Discharge Hospice Item Set, we estimate
that it will take 5 minutes of time by a
clinician such as a nurse at an hourly
wage of $33.23 to abstract data for
Discharge Hospice Item Set. This will
cost the hospice approximately $2.77.
We further estimate that it will take 5
minutes of time by clerical or
administrative staff such as a medical
data entry clerk or medical secretary at
an hourly wage of $15.59 to upload data
into the CMS system. This will cost the
hospice approximately $1.30.
We estimate that the total nursing
time required for completion of both the
admission and discharge assessments is
19 minutes at a rate of $33.23 per hour.
The annualized cost across all Hospices
for the nursing/clinical time required to
complete both the admission and
discharge Hospice Item sets is estimated
to be $11,458,528 and the cost to each
individual Hospice is estimated to be
$3,062.14. The estimated time burden to
hospices for a medical data entry clerk
to complete the admission and
discharge Hospice Item Set assessments
is 10 minutes at a rate of $15.59 per
hour. The cost for completion of the
both the admission and discharge
Hospice Item sets by a medical data
entry clerk is estimated to be $2,829,401
across all Hospices and $756.12 to each
Hospice.
The total combined time burden for
completion of the Admission and
Discharge Hospice Data Item Sets is
estimated to be 29 minutes. The total
annualized cost across all hospices is
estimated to be $14,287,929. For each
individual hospice, this annualized cost
is estimated to be $3,818.26. The
estimated cost for each individual
Hospice Item Set submission is $13.11.
9 14 minutes of time by a Registered Nurse at
$33.23/60 minutes per hour = $0.56; $0.56 per one
minute × 5 minutes = $7.75.
10 5 minutes of time by a Medical Data Entry
Clerk at $15.59/60 minutes per hour = $0.265;
$0.265 per one minute × 5 minutes = $1.30.
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Comment: We received several
comments indicating concern about
general burden that would be associated
with implementing and using the HIS.
Commenters stated hospices will have
to conduct training among staff to
implement and use the HIS, in addition
to staff time that will be required to
complete and submit the HIS.
Commenters also stated that
implementing the HIS will require
modifications to clinical documentation
processes. Some commenters expressed
concerns that implementing the HIS
will concurrently entail both
implementation of a new data collection
tool and implementation of new quality
measures. No commenters stated that
these burdens were great enough to
consider not implementing the HIS for
use in the HQRP.
Response: We recognize these
activities and efforts will be required to
implement and use the HIS as part of
the quality reporting program. We agree
that it is important for Hospices to learn
about and understand the new HIS and
we plan to provide hospices with
training resources to facilitate
implementation of the HIS. We further
acknowledge that specific training costs
were not identified in the proposed rule
because calculating the training burden
is outside the scope of the information
collection requirements.
Comment: A few commenters
expressed concern that the estimated 29
minutes to complete and upload the
admission and discharge HIS was
underestimated. One commenter said
that the estimated 14 minutes for a staff
member to extract data for the
Admission HIS and 5 minutes for the
Discharge HIS seemed accurate, another
commenter indicated that, based on
their experiences with the Home Health
OASIS, they felt the HIS would take
longer than the estimated time.
Response: Burden estimates for
completing the HIS data items were
based on the HIS pilot test. The HIS is
a set of data elements that can be used
to calculate 7 NQF endorsed quality
measures. The HIS is not a patient
assessment that would be administered
to the patient and/or family or
caregivers during the initial assessment
visits; therefore, it cannot be compared
to the OASIS instrument. As the HIS is
not a true patient assessment, the
estimated burden of 14 and 5 minutes
do not include the time a clinician
would spend assessing the patient. The
time estimates are intended to reflect
the time it would take hospice staff to
complete and submit the HIS,
irrespective of clinical activities to
collect initial assessment data. The HIS
pilot demonstrated that hospices use
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varying patient assessment forms during
the initial patient assessment; all
hospices were able to crosswalk items
from their hospice’s patient assessment
forms to the HIS data elements, and
complete the HIS items. Therefore, the
HIS did not add new data collection
efforts to the hospice’s customary
patient initial assessment.
VI. Regulatory Impact Analysis
A. Statement of Need
This final rule follows § 418.306(c),
which requires annual issuance, in the
Federal Register, of the hospice wage
index based on the most current
available CMS hospital wage data. This
rule finalizes hospice payment rates for
FY 2014. In addition, this final rule
provides background on hospice care,
clarifies diagnosis coding on hospice
claims, updates the public on the status
of hospice payment reform, finalizes a
technical and clarifying regulatory text
change, and finalizes changes to the
hospice quality reporting program.
B. Overall Impact
The overall impact of this final rule is
an estimated net increase in Federal
payments to hospices of $160 million,
or 1.0 percent, for FY 2014. This
estimated impact on hospices is a result
of the final hospice payment update
percentage for FY 2014 of 1.7 percent
and changes to the FY 2014 hospice
wage index, including a reduction to the
BNAF by an additional 15 percent, for
a total BNAF reduction of 70 percent (10
percent in FY 2010, and 15 percent per
year for FY 2011 through FY 2014). A
70 percent reduced BNAF is computed
to be 0.018461 (or 1.8461 percent). The
BNAF reduction is part of a 7-year
BNAF phase-out that was finalized in
the August 6, 2009 FY 2010 Hospice
Wage Index final rule (74 FR 39384),
and is not a policy change.
1. Introduction
We have examined the impacts of this
rule as required by Executive Order
12866 on Regulatory Planning and
Review (September 30, 1993), Executive
Order 13563 on Improving Regulation
and Regulatory Review (January 18,
2011), the Regulatory Flexibility Act
(RFA) (September 19, 1980, Pub. L. 96–
354), section 1102(b) of the Act, section
202 of the Unfunded Mandates Reform
Act of 1995 (UMRA, March 22, 1995;
Pub. L. 104–4), and the Congressional
Review Act (5 U.S.C. 804(2)).
Executive Orders 12866 and 13563
direct agencies to assess all costs and
benefits of available regulatory
alternatives and, if regulation is
necessary, to select regulatory
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approaches that maximize net benefits
(including potential economic,
environmental, public health and safety
effects, distributive impacts, and
equity). Executive Order 13563
emphasizes the importance of
quantifying both costs and benefits, of
reducing costs, of harmonizing rules,
and of promoting flexibility. A
regulatory impact analysis (RIA) must
be prepared for major rules with
economically significant effects ($100
million or more in any 1 year). This
final rule has been designated as
economically significant under section
3(f)(1)of Executive Order 12866 and
thus a major rule under the
Congressional Review Act. Accordingly,
we have prepared a regulatory impact
analysis (RIA) that to the best of our
ability presents the costs and benefits of
the rulemaking. Also, the rule has been
reviewed by OMB.
2. Detailed Economic Analysis
This final rule sets forth updates to
the FY 2013 hospice payment rates. The
impact analysis of this final rule
presents the estimated expenditure
effects of policy changes finalized in
this rule. Certain events may limit the
scope or accuracy of our impact
analysis, because such an analysis is
susceptible to forecasting errors due to
other changes in the forecasted impact
time period. The nature of the Medicare
program is such that the changes may
interact, and the complexity of the
interaction of these changes could make
it difficult to predict accurately the full
scope of the impact upon hospices.
Table 11 represents how hospice
revenues are likely to be affected by the
policy changes finalized in this rule. In
column 1 of Table 11, we indicate the
number of hospices included in our
analysis as of December 31, 2012, which
had also filed claims in FY 2012. In
column 2, we indicate the number of
routine home care days that were
included in our analysis, although the
analysis was performed on all types of
hospice care. Column 3 shows the
percentage change in estimated
Medicare payments for FY 2014 due to
the effects of the updated wage data
only, compared with estimated FY 2013
payments. The effect of the updated
wage data can vary from region to region
depending on the fluctuations in the
wage index values of the pre-floor, prereclassified hospital wage index.
Column 4 shows the percentage change
in estimated hospice payments from FY
2013 to FY 2014 due to the combined
effects of using the updated wage data
and reducing the BNAF by an additional
15 percent. Column 5 shows the
percentage change in estimated hospice
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payments from FY 2013 to FY 2014 due
to the combined effects of using updated
wage data, an additional 15 percent
BNAF reduction, and the final 1.7
percent hospice payment update
percentage. Taking into account the 1.7
percent final hospice payment update
percentage (+$280 million), the use of
updated wage index data ($¥20
million), and the additional 15 percent
reduction in the BNAF ($¥100 million),
hospice payments will increase by an
estimated $160 ($280 million¥$20
million ¥$100 million = $160 million)
or 1.0 percent in FY 2014.
The impact of changes in this final
rule has been analyzed according to the
type of hospice, geographic location,
type of ownership, hospice base, and
size. Table 11 categorizes hospices by
various geographic and hospice
characteristics. The first row of data
displays the aggregate result of the
impact for all Medicare-certified
hospices. The second and third rows of
the table categorize hospices according
to their geographic location (urban and
rural). Our analysis indicated that there
are 2,594 hospices located in urban
areas and 975 hospices located in rural
areas. The next two row groupings in
the table indicate the number of
hospices by census region, also broken
down by urban and rural hospices. The
next grouping shows the impact on
hospices based on the size of the
hospice’s program. We determined that
the majority of hospice payments are
made at the routine home care rate.
Therefore, we based the size of each
individual hospice’s program on the
number of routine home care days
provided in FY 2012. The next grouping
shows the impact on hospices by type
of ownership. The final grouping shows
the impact on hospices defined by
whether they are provider-based or
freestanding.
Column 5 of Table 11 shows the
combined effects of the updated wage
data, the additional 15 percent BNAF
reduction, and the final 1.7 percent
hospice payment update percentage on
estimated FY 2014 payments as
compared to estimated FY 2013
payments. Overall, hospices are
anticipated to experience a 1.0 percent
increase in payment, with urban
hospices anticipated to experience a 1.0
percent increase in payments, and rural
hospices anticipated to experience 1.1
percent increase in payments. Urban
hospices are anticipated to experience
an increase in estimated payments in
every region, ranging from 0.3 percent
in the Mountain region to 2.2 percent in
New England. Rural hospices in every
region but one are estimated to see an
increase in payments ranging from 0.4
percent in New England to 1.7 percent
in the East South Central and Outlying
region. The Pacific region is estimated
to see a decrease in payments of 1.2
percent, largely due to fluctuations in
the updated hospital wage index data
used to create the FY 2014 hospice wage
index. Hospital wages in the Pacific
region declined compared to the
previous year, which led to the decrease
in the hospital wage index values, and
which thus affected the FY 2014
hospice wage index values.
Column 5 of Table 11 also shows an
estimated payment increase by hospice
base and hospice size. Payments to
hospices in FY 2014 are estimated to
increase by 1.4 percent for HHA-based
hospices, 1.1 percent for hospital-based
hospices, 1.0 percent for SNF-based
hospices, and by 0.9 percent for
freestanding hospices. Payments to
small hospices (less than 3,500 RHC
days) in FY 2014 are estimated to
increase by 0.8 percent, whereas
payments to large hospices (more than
20,000 RHC days) in FY 2014 are
estimated to increase by 1.0 percent.
TABLE 11—ANTICIPATED IMPACT ON MEDICARE HOSPICE PAYMENTS IN FY 2014 IN UPDATING THE PRE-FLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX DATA, REDUCING THE BUDGET NEUTRALITY ADJUSTMENT FACTOR (BNAF) BY AN
ADDITIONAL 15 PERCENT (FOR A TOTAL BNAF REDUCTION OF 70 PERCENT) AND APPLYING A 1.7 PERCENT HOSPICE
PAYMENT UPDATE PERCENTAGE
emcdonald on DSK67QTVN1PROD with RULES_2
(1)
ALL HOSPICES ...................................................................
URBAN HOSPICES ......................................................
RURAL HOSPICES ......................................................
BY REGION—URBAN:
NEW ENGLAND ...........................................................
MIDDLE ATLANTIC ......................................................
SOUTH ATLANTIC .......................................................
EAST NORTH CENTRAL .............................................
EAST SOUTH CENTRAL .............................................
WEST NORTH CENTRAL ............................................
WEST SOUTH CENTRAL ............................................
MOUNTAIN ...................................................................
PACIFIC ........................................................................
OUTLYING ....................................................................
BY REGION—RURAL:
NEW ENGLAND ...........................................................
MIDDLE ATLANTIC ......................................................
SOUTH ATLANTIC .......................................................
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Percent
change in hospice payments
due to the
wage index
update
(2)
(3)
(4)
Percent
change in hospice payments
due to wage
index update,
additional 15%
reduction in
budget neutrality adjustment and hospice payment
percentage
update
(5)
Number of
hospices
Number of
routine home
care days in
thousands
Percent
change in hospice payments
due to wage
index update,
additional 15%
reduction in
budget neutrality adjustment
3,569
2,594
975
62,945
55,101
7,844
¥0.1
¥0.1
¥0.2
¥0.7
¥0.7
¥0.6
1.0
1.0
1.1
129
249
378
338
155
197
517
263
333
35
1,472
5,702
13,173
7,224
3,278
2,494
6,622
5,698
8,141
1,296
1.1
0.0
¥0.7
0.0
¥0.5
0.4
¥0.4
¥0.8
0.9
0.3
0.5
¥0.6
¥1.3
¥0.6
¥1.0
¥0.2
¥1.0
¥1.4
0.2
0.3
2.2
1.1
0.4
1.1
0.7
1.5
0.7
0.3
1.9
2.0
24
43
135
195
439
1,918
¥0.7
¥0.1
¥0.3
¥1.3
¥0.7
¥0.7
0.4
1.0
1.0
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48279
TABLE 11—ANTICIPATED IMPACT ON MEDICARE HOSPICE PAYMENTS IN FY 2014 IN UPDATING THE PRE-FLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX DATA, REDUCING THE BUDGET NEUTRALITY ADJUSTMENT FACTOR (BNAF) BY AN
ADDITIONAL 15 PERCENT (FOR A TOTAL BNAF REDUCTION OF 70 PERCENT) AND APPLYING A 1.7 PERCENT HOSPICE
PAYMENT UPDATE PERCENTAGE—Continued
(1)
EAST NORTH CENTRAL .............................................
EAST SOUTH CENTRAL .............................................
WEST NORTH CENTRAL ............................................
WEST SOUTH CENTRAL ............................................
MOUNTAIN ...................................................................
PACIFIC ........................................................................
OUTLYING ....................................................................
BY SIZE/DAYS:
0–3499 DAYS (small) ...................................................
3500–19,999 DAYS (medium) ......................................
20,000+ DAYS (large) ..................................................
TYPE OF OWNERSHIP:
VOLUNTARY ................................................................
PROPRIETARY ............................................................
GOVERNMENT ................................................................
HOSPICE BASE:2
FREESTANDING ..........................................................
HOME HEALTH AGENCY ...........................................
HOSPITAL ....................................................................
SKILLED NURSING FACILITY ....................................
Percent
change in hospice payments
due to the
wage index
update
(2)
(3)
(4)
Percent
change in hospice payments
due to wage
index update,
additional 15%
reduction in
budget neutrality adjustment and hospice payment
percentage
update
(5)
Number of
hospices
Number of
routine home
care days in
thousands
Percent
change in hospice payments
due to wage
index update,
additional 15%
reduction in
budget neutrality adjustment
138
134
182
176
95
47
1
1,154
1,529
604
977
568
445
15
0.4
0.1
¥0.8
¥0.1
0.4
¥2.2
0.0
¥0.2
0.0
¥1.2
¥0.2
¥0.1
¥2.8
0.0
1.5
1.7
0.5
1.5
1.6
¥1.2
1.7
841
1815
913
1,373
17,403
44,168
¥0.3
¥0.2
¥0.1
¥0.8
¥0.7
¥0.7
0.8
1.0
1.0
1080
2002
487
23,296
32,992
6,656
0.0
¥0.3
¥0.1
¥0.5
¥0.9
¥0.7
1.1
0.8
1.0
2569
522
458
20
50,665
7,728
4,430
122
¥0.2
0.3
0.0
0.0
¥0.8
¥0.3
¥0.6
¥0.7
0.9
1.4
1.1
1.0
Source: Provider data as of December 31, 2012 for hospices with claims filed in FY 2012 (Based on the 2012 standard analytic file (SAF).
Note(s): The final 1.7 percent hospice payment update percentage for FY 2014 is based on an estimated 2.5 percent inpatient hospital market
basket update, reduced by a 0.5 percentage point productivity adjustment and by 0.3 percentage point; these reductions were mandated by section 3401(g) of ACA.
REGION KEY:
New England = Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont; Middle Atlantic = Pennsylvania, New Jersey,
New York; South Atlantic = Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia;
East North Central = Illinois, Indiana, Michigan, Ohio, Wisconsin; East South Central = Alabama, Kentucky, Mississippi, Tennessee; West North
Central = Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota; West South Central = Arkansas, Louisiana, Oklahoma,
Texas; Mountain = Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming; Pacific = Alaska, California, Hawaii, Oregon,
Washington; Outlying = Guam, Puerto Rico, Virgin Islands
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3. Cost Allocation of Quality Reporting
This final rule also implements a
hospice patient-level data set to be used
by all hospices to collect and submit
standardized data about each patient
admitted to hospice. This Hospice Item
Set will be used to support the
standardized collection and calculation
of quality measures, collection of the
requisite data elements. Hospices will
be required to complete and submit an
admission HIS and a discharge HIS on
all patients admitted to hospice starting
July 1, 2014 for FY 2016 APU
determination. The admission and
discharge HIS will collect the
standardized data elements needed to
calculate 7 NQF endorsed measures for
hospice. The total annualized cost
across all hospices, starting July 2014, is
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estimated to be $14,287,929.
Furthermore, the structural measure
related to QAPI indicators and the NQF
#0209 pain measure will no longer be
required for the hospice quality
reporting program beyond data
submission for the FY 2015 payment
determination. The original intent of the
structural measure was for hospices to
submit information about number, type,
and data source of quality indicators
used as a part of their QAPI Program.
Data gathered as part of the structural
measure were used to ascertain the
breadth and context of existing hospice
QAPI programs to inform future
measure development activities
including the data collection approach
for the first year of required reporting
(FY 2014). Please refer to section B, the
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Hospice Quality Reporting Program, for
a detailed discussion of these programs.
4. Alternatives Considered
In continuing the reduction to the
BNAF by an additional 15 percent, for
a total BNAF reduction of 70 percent (10
percent in FY 2010, and 15 percent per
year for FY 2011 through FY 2014), and
implementing the hospice payment
update percentage and the updated
wage index, the aggregate impact will be
a net increase of $160 million in
payments to hospices. In the proposed
rule for FY 2014, we did not consider
discontinuing the additional 15 percent
reduction to the BNAF as the 7-year
phase-out of the BNAF was finalized in
the FY 2010 Hospice Wage Index final
rule (74 FR 39384). However, if we were
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to discontinue the reduction to the
BNAF by an additional 15 percent,
Medicare would pay an estimated $100
million more to hospices in FY 2014.
The final 1.7 percent hospice payment
update percentage for FY 2014 is based
on a final 2.5 percent inpatient hospital
market basket update for FY 2014,
reduced by a 0.5 percentage point
productivity adjustment and by an
additional 0.3 percentage point.
Payment rates for FYs since 2002 have
been updated according to section
1814(i)(1)(C)(ii)(VII) of the Act, which
states that the update to the payment
rates for subsequent FYs must be the
market basket percentage for that FY.
The Act requires us to use the inpatient
hospital market basket to determine the
hospice payment rate update. In
addition, section 3401(g) of the
Affordable Care Act mandates that,
starting with FY 2013 (and in
subsequent FYs), the hospice payment
update percentage will be annually
reduced by changes in economy-wide
productivity as specified in section
1886(b)(3)(B)(xi)(II) of the Act. In
addition, section 3401(g) of the
Affordable Care Act also mandates that
in FY 2013 through FY 2019, the
hospice payment update percentage will
be reduced by an additional 0.3
percentage point (although for FY 2014
to FY 2019, the potential 0.3 percentage
point reduction is subject to suspension
under conditions specified in section
1814(i)(1)(C)(v) of the Act). Since the
hospice payment update percentage is
determined based on statutory
requirements, we did not consider not
updating hospice payment rates by the
payment update percentage.
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C. Accounting Statement
As required by OMB Circular A–4
(available at https://
www.whitehouse.gov/omb/circulars/
a004/a-4.pdf), in Table 12 below, we
have prepared an accounting statement
showing the classification of the
expenditures associated with this final
rule. Table 12 provides our best estimate
of the increase in FY 2014 Medicare
payments under the hospice benefit as
a result of the changes presented in this
final rule using data for 3,569 hospices
in our database. In addition, the table
presents the costs to hospice providers
for submitting data to the Hospice Item
Set starting in July 2014.
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TABLE 12—ACCOUNTING STATEMENT:
CLASSIFICATION OF ESTIMATED EXPENDITURES, FROM FY 2013 TO FY
2014
[In $millions]
Category
Annualized Monetized
Transfers.
From Whom to Whom
Transfers
$160.
Federal Government
to Hospices.
Category
Annualized Monetized
Costs for Hospices
to Submit Data*.
Costs
$14.3.
* All hospices are required to submit data for
the Hospice Item Set starting in July of 2014.
D. Conclusion
In conclusion, the overall effect of this
final rule is an estimated $160 million
increase in Federal Medicare payments
to hospices due to the wage index
changes (including the additional 15
percent reduction in the BNAF) and the
final hospice payment update
percentage of 1.7 percent. Furthermore,
hospices are estimated to incur total
costs of $14.3 million as a result of data
submission requirements starting in July
2014. Lastly, the Secretary has
determined that this final rule will not
have a significant impact on a
substantial number of small entities, or
have a significant effect relative to
section 1102(b) of the Act.
1. Regulatory Flexibility Act Analysis
The RFA requires agencies to analyze
options for regulatory relief of small
businesses if a rule has a significant
impact on a substantial number of small
entities. For purposes of the RFA, we
estimate that almost all hospices are
small entities as that term is used in the
RFA. The great majority of hospitals and
most other health care providers and
suppliers are small entities by meeting
the Small Business Administration
(SBA) definition of a small business (in
the service sector, having revenues of
less than $7.0 million to $34.5 million
in any 1 year), or being nonprofit
organizations. While the SBA does not
define a size threshold in terms of
annual revenues for hospices, it does
define one for home health agencies
($14 million; see https://www.sba.gov/
sites/default/files/files/
Size_Standards_Table(1).pdf). For the
purposes of this final rule, because the
hospice benefit is a home-based benefit,
we are applying the SBA definition of
‘‘small’’ for home health agencies to
hospices; we will use this definition of
‘‘small’’ in determining if this final rule
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Fmt 4701
Sfmt 4700
has a significant impact on a substantial
number of small entities (for example,
hospices). We estimate that 95 percent
of hospices have Medicare revenues
below $14 million or are nonprofit
organizations and therefore are
considered small entities.
HHS’s practice in interpreting the
RFA is to consider effects economically
‘‘significant’’ only if they reach a
threshold of 3 to 5 percent or more of
total revenue or total costs. As noted
above, the combined effect of the
updated wage data, the additional 15
percent BNAF reduction, and the final
FY 2014 hospice payment update
percentage of 1.7 percent results in an
increase in estimated hospice payments
of 1.0 percent for FY 2014. For small
and medium hospices (as defined by
routine home care days), the estimated
effects on revenue when accounting for
the updated wage data, the additional
15 percent BNAF reduction, and the
final FY 2014 hospice payment update
percentage reflect increases in payments
of 0.8 percent and 1.0 percent,
respectively. Therefore, the Secretary
has determined that this final rule will
not create a significant economic impact
on a substantial number of small
entities.
In addition, section 1102(b) of the Act
requires us to prepare a regulatory
impact analysis if a rule may have a
significant impact on the operations of
a substantial number of small rural
hospitals. This analysis must conform to
the provisions of section 604 of the
RFA. For purposes of section 1102(b) of
the Act, we define a small rural hospital
as a hospital that is located outside of
a metropolitan statistical area and has
fewer than 100 beds. This final rule only
affects hospices. Therefore, the
Secretary has determined that this final
rule will not have a significant impact
on the operations of a substantial
number of small rural hospitals.
2. Unfunded Mandates Reform Act
Analysis
Section 202 of the Unfunded
Mandates Reform Act of 1995 also
requires that agencies assess anticipated
costs and benefits before issuing any
rule whose mandates require spending
in any 1 year of $100 million in 1995
dollars, updated annually for inflation.
In 2013, that threshold is approximately
$141 million. This final rule is not
anticipated to have an effect on State,
local, or tribal governments, in the
aggregate, or on the private sector of
$141 million or more.
Comment: We received a few
comments on Unfunded Mandates
Reform Act Analysis section.
Commenters disagreed that we did not
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emcdonald on DSK67QTVN1PROD with RULES_2
meet the statutory threshold of the
Unfunded Mandates Reform Act of
1995. A commenter stated that the total
costs of additional staff time,
professional consulting fees and
software necessary to comply fully with
the new billing; coding, quality
reporting and survey administration
tasks will exceed that threshold figure of
$141 million.
Response: The hospice benefit covers
all care for the terminal prognosis,
related conditions, and for the
management of pain and symptoms.
HIPAA, federal regulations, and the
Medicare hospice claims processing
manual all require that ICD–9–CM
Coding Guidelines be applied to the
coding and reporting of diagnoses on
hospice claims. In our regulations at 45
CFR 162.1002, the Secretary adopted the
ICD–9–CM code set, including The
Official ICD–9–CM Guidelines for
Coding and Reporting. The CMS’
Hospice Claims Processing manual (Pub
100–04, chapter 11) requires that
hospice claims include other diagnoses
‘‘as required by ICD–9–CM Coding
Guidelines.’’ In the proposed rule, we
provided guidance from the ICD–9–CM
Official Guidelines for Coding and
Reporting to highlight coding guidelines
for principal and other diagnosis
selection, as well as the various coding
and sequencing conventions found
therein. We are not requiring any new
ICD–9–CM coding guidelines in this
rule, rather we are reiterating existing
policies and reminding providers of the
expectations in regards to diagnostic
coding on hospice claims. In addition,
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as indicated in section V of this final
rule, we set out the requirements and
burden estimates for the Hospice
Experience of Care Survey field study
and indicated that it is too early to set
out the requirements and burden
estimates for the national
implementation of the survey. We
anticipate having the final survey
instrument in 2014 and setting out the
collection of information requirements
and burden estimates in the proposed
rule for CY 2015. In addition, we
provided a burden estimate for the
Hospice Item Set that providers will be
required to submit starting FY 2015,
with a total annualized cost across all
hospices estimated at $14,287,929.
Therefore, we do not believe that any
clarifications or requirements
promulgated in this rule exceed the
Unfunded Mandates Reform Act
threshold.
VII. Federalism Analysis and
Regulations Text
Executive Order 13132 on Federalism
(August 4, 1999) establishes certain
requirements that an agency must meet
when it promulgates a proposed rule
(and subsequent final rule) that imposes
substantial direct requirement costs on
State and local governments, preempts
State law, or otherwise has Federalism
implications. We have reviewed this
final rule under the threshold criteria of
Executive Order 13132, Federalism, and
have determined that it will not have
substantial direct effects on the rights,
roles, and responsibilities of States,
local or tribal governments.
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48281
List of Subjects in 42 CFR Part 418
Health facilities, Hospice care,
Medicare, Reporting and recordkeeping
requirements.
For the reasons set forth in the
preamble, the Centers for Medicare &
Medicaid Services proposes to amend
42 CFR part 418 as set forth below:
PART 418—HOSPICE CARE
1. The authority citation for part 418
continues to read as follows:
■
Authority: Secs. 1102 and 1871 of the
Social Security Act (42 U.S.C. 1302 and
1395hh).
§ 418.311
[Amended]
2. Amend § 418.311 by removing the
reference to ‘‘§ 405.1874’’ and adding in
its place the reference ‘‘§ 405.1875’’.
■
(Catalog of Federal Domestic Assistance
Program No. 93.778, Medical Assistance
Program) (Catalog of Federal Domestic
Assistance Program No. 93.773, Medicare—
Hospital Insurance; and Program No. 93.774,
Medicare—Supplementary Medical
Insurance Program)
Dated: July 24, 2013.
Marilyn Tavenner,
Administrator, Centers for Medicare &
Medicaid Services.
Approved: July 30, 2013.
Kathleen Sebelius,
Secretary, Department of Health and Human
Services.
[FR Doc. 2013–18838 Filed 8–2–13; 4:15 pm]
BILLING CODE 4120–01–P
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]]>Agencies
[Federal Register Volume 78, Number 152 (Wednesday, August 7, 2013)]
[Rules and Regulations]
[Pages 48233-48281]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2013-18838]
[[Page 48233]]
Vol. 78
Wednesday,
No. 152
August 7, 2013
Part II
Department of Health and Human Services
-----------------------------------------------------------------------
Center for Medicare & Medicaid Services
42 CFR Part 418
Medicare Program; FY 2014 Hospice Wage Index and Payment Rate Update;
Hospice Quality Reporting Requirements; and Updates on Payment Reform;
Final Rule
Federal Register / Vol. 78 , No. 152 / Wednesday, August 7, 2013 /
Rules and Regulations
[[Page 48234]]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Part 418
[CMS-1449-F]
RIN 0938-AR64
Medicare Program; FY 2014 Hospice Wage Index and Payment Rate
Update; Hospice Quality Reporting Requirements; and Updates on Payment
Reform
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final rule.
-----------------------------------------------------------------------
SUMMARY: This final rule updates the hospice payment rates and the wage
index for fiscal year (FY) 2014, and continues the phase out of the
wage index budget neutrality adjustment factor (BNAF). Including the FY
2014 15 percent BNAF reduction, the total 5 year cumulative BNAF
reduction in FY 2014 will be 70 percent. The BNAF phase-out will
continue with successive 15 percent reductions in FY 2015 and FY 2016.
This final rule also clarifies how hospices are to report diagnoses on
hospice claims, and provides updates to the public on hospice payment
reform. Additionally, this final rule changes the requirements for the
hospice quality reporting program by discontinuing currently reported
measures and implementing a Hospice Item Set with seven National
Quality Forum (NFQ) endorsed measures beginning July 1, 2014, as
proposed. Finally, this final rule will implement the hospice
Experience of Care Survey on January 1, 2015, as proposed.
DATES: Effective Date: These regulations are effective on October 1,
2013.
FOR FURTHER INFORMATION CONTACT:
Debra Dean-Whittaker, (410) 786-0848, for questions regarding the
hospice experience of care survey.
Robin Dowell, (410) 786-0060, for questions regarding quality reporting
for hospices and collection of information requirements.
Hillary Loeffler, (410) 786-0456, for general questions about hospice
payment.
Katherine Lucas, (410) 786-7723 for questions regarding payment reform.
Anjana Patel, (410) 786-2120, for questions regarding the FY 2014
hospice wage index and payment rates.
Kelly Vontran, (410) 786-0332, for questions on diagnosis reporting on
hospice claims.
SUPPLEMENTARY INFORMATION:
Wage Index Addenda: In the past, the wage index addenda referred to
in the preamble of our proposed and final rules were available in the
Federal Register. However, the wage index addenda of the annual
proposed and final rules will no longer be available in the Federal
Register. Instead, these addenda will be available only through the
internet on the CMS Web site at: (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/.) Readers who experience any
problems accessing any of the wage index addenda related to the hospice
payment rules that are posted on the CMS Web site identified above
should contact Anjana Patel at 410-786-2120.
Table of Contents
I. Executive Summary
A. Purpose
B. Summary of the Major Provisions
C. Summary of Costs, Benefits, and Transfers
II. Background
A. Hospice Care
B. History of the Medicare Hospice Benefit
C. Services Covered by the Medicare Hospice Benefit
D. Medicare Payment for Hospice Care
1. Omnibus Budget Reconciliation Act of 1989
2. Balanced Budget Act of 1997
3. FY 1998 Hospice Wage Index Final Rule
4. FY 2010 Hospice Wage Index Final Rule
5. The Affordable Care Act
6. FY 2012 Hospice Wage Index Final Rule
E. Trends in Medicare Hospice Utilization
III. Summary of the Provisions of the Proposed Rule
A. Diagnosis Reporting on Hospice Claims
1. ICD-9-CM Coding Guidelines
2. Use of Nonspecific, Symptom Diagnoses
3. Use of ``Mental, Behavioral and Neurodevelopmental
Disorders'' ICD-9-CM Codes
4. Guidance on Coding of Principal and Other, Additional, and/or
Co-Existing Diagnoses
5. Transition to ICD-10-CM
B. Hospice Quality Reporting Program
C. FY 2014 Hospice Wage Index and Rates Update
D. Update on Hospice Payment Reform and Data Collection
E. Technical and Clarifying Regulatory Text Change
IV. Analysis and Responses to Public Comments
A. Diagnosis Reporting on Hospice Claims
1. ICD-9-CM Coding Guidelines
2. Use of Nonspecific, Symptom Diagnoses
3. Use of ``Mental, Behavioral and Neurodevelopmental
Disorders'' ICD-9-CM Codes
4. Guidance on Coding of Principal and Other, Additional, and/or
Co-Existing Diagnoses
5. Transition to ICD-10-CM
B. The Hospice Quality Reporting Program
1. Background and Statutory Authority
2. Quality Measures for Hospice Quality Reporting Program and
Data Submission Requirements for Payment Year FY 2014
3. Quality Measures for Hospice Quality Reporting Program and
Data Submission Requirements for Payment Year FY 2015 and Beyond
4. Quality Measures for Hospice Quality Reporting Program for
Payment Year FY 2016 and Beyond
5. Public Availability of Data Submitted
6. The CMS Hospice Experience of Care Survey for the FY 2017
Payment Determination and That of Subsequent Fiscal Years
7. Notice Pertaining to Reconsiderations Following APU
Determinations
C. FY 2014 Hospice Wage Index and Rates Update
1. Hospice Wage Index
2. FY 2014 Wage Index With an Additional 15 Percent Reduced
Budget Neutrality Adjustment Factor (BNAF)
3. Hospice Payment Update Percentage
4. Final FY 2014 Hospice Payment Rates
D. Update on Hospice Payment Reform and Data Collection
1. Update on Reform Options
a. Rebasing the Routine Home Care (RHC) Rate
b. Site of Service Adjustment for Hospice Patients in Nursing
Facilities
2. Reform Research Findings
3. Additional Data Collection
E. Technical and Clarifying Regulatory Text Change
V. Collection of Information Requirements
VI. Regulatory Impact Analysis
A. Statement of Need
B. Overall Impact
1. Introduction
2. Detailed Economic Analysis
3. Cost Allocation of Quality Reporting
4. Alternatives Considered
C. Accounting Statement
D. Conclusion
1. Regulatory Flexibility Act Analysis
2. Unfunded Mandates Reform Act Analysis
VII. Federalism Analysis and Regulations Text
Acronyms
Because of the many terms to which we refer by acronym in this
final rule, we are listing the acronyms used and their corresponding
meanings in alphabetical order below:
APU Annual Payment Update
BBA Balanced Budget Act of 1997
BLS Bureau of Labor Statistics
BMI Body Mass Index
BNAF Budget Neutrality Adjustment Factor
CAD Coronary Artery Disease
CAHPS[supreg] Consumer Assessment of Healthcare Providers and
Systems
CBSA Core-Based Statistical Area
CCW Chronic Conditions Warehouse
CFR Code of Federal Regulations
CHC Continuous Home Care
CMS Centers for Medicare & Medicaid Services
COPD Chronic Obstructive Pulmonary Disease
CoPs Conditions of Participation
[[Page 48235]]
CR Change Request
CVA Cerebrovascular Accident
CY Calendar Year
DME Durable Medical Equipment
FEHC Family Evaluation of Hospice Care
FR Federal Register
FY Fiscal Year
GAO Government Accountability Office
GIP General Inpatient Care
HCFA Healthcare Financing Administration
HHS Health and Human Services
HIS Hospice Item Set
HQRP Hospice Quality Reporting Program
ICD-9-CM International Classification of Diseases, Ninth Revision,
Clinical Modification
ICD-10-CM International Classification of Diseases, Tenth Revision,
Clinical Modification
IDG Interdisciplinary Group
IPPS Inpatient Prospective Payment System
IRC Inpatient Respite Care
LCD Local Coverage Determination
LUPA Low Utilization Payment Amount
MAP Measure Applications Partnership
MedPAC Medicare Payment Advisory Commission
MFP Multi-factor Productivity
MSA Metropolitan Statistical Area
NEC Not Elsewhere Classified
NF Long Term Care Nursing Facility
NPI National Provider Identifier
NQF National Quality Forum
OACT Office of the Actuary
OIG Office of Inspector General
OMB Office of Management and Budget
PEACE Prepare, Embrace, Attend, Communicate, and Empower
PRA Paperwork Reduction Act
PRRB Provider Reimbursement Review Board
QAPI Quality Assessment and Performance Improvement
RFA Regulatory Flexibility Act
RHC Routine Home Care
SBA Small Business Administration
SNF Skilled Nursing Facility
TEFRA Tax Equity and Fiscal Responsibility Act of 1982
TEP Technical Expert Panel
I. Executive Summary
A. Purpose
This final rule updates the payment rates for hospice providers for
fiscal year (FY) 2014 as required under section 1814 (i) of the Social
Security Act (the Act). The updates incorporate the use of updated
hospital wage index data, the 5th year of the 7-year Budget Neutrality
Adjustment Factor (BNAF) phase-out, and an update to the hospice
payment rates by the hospice payment update percentage. Additionally,
this final rule clarifies diagnosis reporting on hospice claims,
provides an update on hospice payment reform and additional data
collection requirements, and makes changes to the quality reporting
requirements for hospice providers.
B. Summary of the Major Provisions
In this final rule we update the hospice payment rates for FY 2014
by 1.7 percent as described in section IV.C.3. We also update the FY
2014 hospice wage index with more current wage data, and the BNAF will
be reduced by an additional 15 percent for a total BNAF reduction of 70
percent as described in section IV.C.3. The August 6, 2009 FY 2010
Hospice Wage Index final rule (74 FR 39384) finalized a 10 percent
reduced BNAF for FY 2010 as the first year of a 7-year phase-out of the
BNAF, to be followed by an additional 15 percent per year reduction in
the BNAF in each of the next 6 years. The total BNAF phase-out will be
complete by FY 2016. This final rule also clarifies diagnosis reporting
on hospice claims, especially regarding the use of non-specific symptom
diagnoses; provides an update on hospice payment reform and additional
data collection requirements; and finalizes a technical regulations
text change. Additionally, this final rule changes the requirements for
the hospice quality reporting program by discontinuing currently
reported measures and implementing a Hospice Item Set with seven
National Quality Forum (NQF) endorsed measures beginning July 1, 2014,
as proposed. Finally, this final rule will implement the hospice
Experience of Care Survey on January 1, 2015, as proposed.
C. Summary of Costs, Benefits, and Transfers
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Provision description Total
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FY 2014 Hospice Payment Rate The overall economic impact of this final
Update. rule is an estimated $160 million in
increased payments to hospices.
Costs for Hospices to Submit The total cost to hospice providers, for
Data. submitting data to the Hospice Item Set
starting in July 2014, is $14.3 million.
------------------------------------------------------------------------
II. Background
A. Hospice Care
Coping with a life-limiting illness can be an overwhelming
experience, physically, emotionally and spiritually, for both the
person and his or her family. Recognition that the care needs at end-
of-life are different from other health care needs is a foundation of
the Medicare Hospice Benefit. Hospice is a compassionate care
philosophy and practice for those who are terminally ill. It is a
holistic approach to treatment that recognizes that the impending death
of an individual warrants a change from curative to palliative care.
Palliative care means ``patient and family-centered care that optimizes
quality of life by anticipating, preventing, and treating suffering.
Palliative care throughout the continuum of illness involves addressing
physical, intellectual, emotional, social, and spiritual needs and to
facilitate patient autonomy, access to information, and choice'' (42
CFR 418.3). Palliative care is at the core of hospice philosophy and
care practices. The person beginning hospice care, or his or her
representative, needs to understand that his or her illness is no
longer responding to medical interventions to cure or slow the
progression of disease and then must choose to stop further curative
attempts while palliative care continues and intensifies, as needed,
for continued symptom management. As we stated in the June 5, 2008
Hospice Conditions of Participation final rule (73 FR 32088),
palliative care is an approach that ``optimizes quality of life by
anticipating, preventing, and treating suffering.'' The goal of
palliative care in hospice is to improve the quality of life of
individuals and their families facing the issues associated with life-
threatening illness through the prevention and relief of suffering by
means of early identification, assessment and treatment of pain and
other issues. In addition, palliative care in hospice includes
coordinating care services, reducing unnecessary diagnostics or
ineffective therapies, and offering ongoing conversations with
individuals and their families about changes in the disease and shifts
in the plan of care to meet the changing needs with disease progression
as the individual approaches the end-of-life.
Medicare hospice care is palliative care for individuals with a
prognosis of living 6 months or less if the terminal illness runs its
normal course. As generally accepted by the medical community, the term
``terminal illness'' refers to an advanced and progressively
deteriorating illness, and the illness is diagnosed as incurable. When
an individual is terminally ill, many health problems are brought on by
underlying
[[Page 48236]]
condition(s), as bodily systems are interdependent. In the June 5, 2008
Hospice Conditions of Participation final rule (73 FR 32088), we stated
``the medical director must consider the primary terminal condition,
related diagnoses, current subjective and objective medical findings,
current medication and treatment orders, and information about
unrelated conditions when considering the initial certification of the
terminal illness.'' As referenced in our regulations at 42 CFR
418.22(b)(1), to be eligible for Medicare hospice services, the
beneficiary's attending physician (if any) and the hospice medical
director must certify that the individual is terminally ill, that is,
the individual's prognosis is for a life expectancy of 6 months or less
if the terminal illness runs its normal course as defined in section
1861(dd)(3)(A) of the Act and our regulations at Sec. 418.3. The
certification of terminal illness must include a brief narrative
explanation of the clinical findings that supports a life expectancy of
6 months or less as part of the certification and recertification forms
as stated in Sec. 418.22(b)(3).
The goal of hospice care is to make the hospice patient as
physically and emotionally comfortable as possible, with minimal
disruption to normal activities, while remaining primarily in the home
environment. Hospice care uses an interdisciplinary approach to deliver
medical, nursing, social, psychological, emotional, and spiritual
services through the use of a broad spectrum of professional and other
caregivers and volunteers. While the goal of hospice care is to allow
for the individual to remain in his or her home environment,
circumstances during the end-of-life may necessitate short-term
inpatient admission to a hospital, skilled nursing facility (SNF), or
hospice facility for procedures necessary for pain control or acute or
chronic symptom management that cannot be managed in any other setting.
These acute hospice care services are to ensure that any new or
worsening symptoms are intensively addressed so that the individual can
return to his or her home environment under routine hospice care.
Short-term, intermittent, inpatient respite services are also available
to the family of the hospice patient when needed to relieve the family
or other caregivers. Additionally, an individual can receive continuous
home care during a period of crisis in which an individual requires
primarily continuous nursing care to achieve palliation or management
of acute medical symptoms so that the individual can remain at home.
Continuous home care may be covered on a continuous basis for as much
as 24 hours a day, and these periods must be predominantly nursing care
per our regulations at Sec. 418.204. A minimum of 8 hours of care must
be furnished on a particular day to qualify for the continuous home
care rate (Sec. 418.302(e)(4)).
B. History of the Medicare Hospice Benefit
Before the creation of the Medicare Hospice Benefit, hospice was
originally run by volunteers who cared for the dying. During the early
development stages of the Medicare Hospice Benefit, hospice advocates,
working with legislators, were clear that they wanted a Medicare
benefit available that provided all-inclusive care for terminally-ill
individuals, provided pain relief and symptom management, and offered
the opportunity to die with dignity in the comfort of one's home rather
than in an institutional setting.\1\ As stated in the August 22, 1983
proposed rule entitled ``Medicare Program; Hospice Care'' (48 FR
38146), ``the hospice experience in the United States has placed
emphasis on home care. It offers physician services, specialized
nursing services, and other forms of care in the home to enable the
terminally ill individual to remain at home in the company of family
and friends as long as possible.'' The concept of a beneficiary
``electing'' the hospice benefit and being certified as terminally ill
were two key components in the legislation responsible for the creation
of the Medicare Hospice Benefit (section 122 of the Tax Equity and
Fiscal Responsibility Act of 1982 (TEFRA), (Pub. L. 97-248)). Section
122 of TEFRA created the Medicare Hospice Benefit, which was
implemented on November 1, 1983. Under section 1861(dd) of the Social
Security Act (the Act), codified at 42 U.S.C. 1395x(dd), we provide
coverage of hospice care for terminally ill Medicare beneficiaries who
elected to receive care from a Medicare-certified hospice. Our
regulations at Sec. 418.54(c) stipulate that the comprehensive hospice
assessment must identify the patient's physical, psychosocial,
emotional, and spiritual needs related to the terminal illness and
related conditions, and address those needs in order to promote the
hospice patient's well-being, comfort, and dignity throughout the dying
process. The comprehensive assessment must take into consideration the
following factors: the nature and condition causing admission
(including the presence or lack of objective data and subjective
complaints); complications and risk factors that affect care planning;
functional status; imminence of death; and severity of symptoms. The
Medicare Hospice Benefit requires the hospice to cover all reasonable
and necessary palliative care related to the terminal prognosis and
related conditions, as described in the patient's plan of care. The
December 16, 1983 Hospice final rule (48 FR 56008) requires hospices to
cover care for interventions to manage pain and symptoms. Clinically,
related conditions are any physical or mental conditions that are
related to or caused by either the terminal illness or the medications
used to manage the terminal illness.\2\ Additionally, the hospice
Conditions of Participation at Sec. 418.56(b), hospice must provide
all services necessary for the palliation and management of the
terminal illness, related conditions and interventions to manage pain
and symptoms. Therapy and interventions must be assessed and managed in
terms of providing palliation and comfort without undue symptom burden
for the hospice patient or family.\3\ For example, a hospice patient
with lung cancer (the terminal illness) may receive inhalants for
shortness of breath (related to the terminal condition). The patient
may also suffer from metastatic bone pain (a related condition) and
would be treated with opioid analgesics. As a result of the opioid
therapy, the patient may suffer from constipation (an associated
symptom) and require a laxative for symptom relief. It is often not a
single diagnosis that represents the terminal prognosis of the patient,
but the combined effect of several conditions that makes the patient's
condition terminal. We are restating what we communicated in the
December 16, 1983 Hospice final rule (48 FR 56010), regarding what is
related versus unrelated to the terminal illness: ``. . . we believe
that the unique physical condition of each terminally ill individual
makes it necessary for these decisions to be made on a case-by-case
basis. It is our general view that hospices are required to provide
virtually all the care that is needed by terminally ill patients.''
Therefore, unless there is clear evidence that a
[[Page 48237]]
condition is unrelated to the terminal prognosis, all services would be
considered related. It is also the responsibility of the hospice
physician to document why a patient's medical needs would be unrelated
to the terminal prognosis.
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\1\ Connor, Stephen (2007). Development of Hospice and
Palliative Care in the United States. OMEGA. 561(1), p. 89-99.
\2\ Harder, PharmD, CGP, Julia. (2012). To Cover or Not To
Cover: Guidelines for Covered Medications in Hospice Patients. The
Clinician. 7(2), p. 1-3.
\3\ Paolini, DO, Charlotte. (2001). Symptoms Management at End
of Life. JAOA. 101(10). p. 609-615.
---------------------------------------------------------------------------
The fundamental premise upon which the hospice benefit was designed
was the ``revocation'' of traditional curative care and the
``election'' of hospice care for end-of-life symptom management and
maximization of quality of life, as stated in the December 16,1983
Hospice final rule (48 FR 56008). After electing hospice care, the
patient typically returns to the home from an institutionalized setting
or remains in the home, to be surrounded by family and friends, and to
prepare emotionally and spiritually for death while receiving expert
symptom management and other supportive services. Election of hospice
care also includes waiving the right to Medicare payment for curative
treatment for the terminal prognosis, and instead receiving palliative
care to manage pain or symptoms.
The benefit was originally designed to cover hospice care for a
finite period of time that roughly corresponded to a life expectancy of
6 months or less. Initially, beneficiaries could receive three election
periods: Two 90-day periods and one 30-day period. Currently, Medicare
beneficiaries can elect hospice care for two 90-day periods and an
unlimited number of subsequent 60-day periods; however, the expectation
remains that beneficiaries have a life expectancy of 6 months or less
if the terminal illness runs its normal course.
C. Services Covered by the Medicare Hospice Benefit
One requirement for coverage under the Medicare Hospice Benefit is
that hospice services must be reasonable and necessary for the
palliation and management of the terminal illness and related
conditions. Section 1861(dd)(1) of the Act establishes the services
that are to be rendered by a Medicare certified hospice program. These
covered services include: Nursing care; physical therapy; occupational
therapy; speech-language pathology therapy; medical social services;
home health aide services (now called hospice aide services); physician
services; homemaker services; medical supplies (including drugs and
biologics); medical appliances; counseling services (including dietary
counseling); short-term inpatient care (including both respite care and
procedures necessary for pain control and acute or chronic symptom
management) in a hospital, nursing facility, or hospice inpatient
facility; continuous home care during periods of crisis and only as
necessary to maintain the terminally ill individual at home; and any
other item or service which is specified in the plan of care and for
which payment may otherwise be made under Medicare, in accordance with
Title XVIII of the Act.
Section 1814(a)(7)(B) of the Act requires that a written plan for
providing hospice care to a beneficiary who is a hospice patient be
established before care is provided by, or under arrangements made by,
that hospice program and that the written plan be periodically reviewed
by the beneficiary's attending physician (if any), the hospice medical
director, and an interdisciplinary group (described in section
1861(dd)(2)(B) of the Act).
The services offered under the hospice benefit must be available,
as needed, to beneficiaries 24 hours a day, 7 days a week (section
1861(dd)(2)(A)(i) of the Act). Upon the implementation of the hospice
benefit, the Congress expected hospices to continue to use volunteer
services, though these services are not to be reimbursed (see Section
1861(dd)(2)(E) of the Act and 48 FR 38149). The hospice
interdisciplinary group should be comprised of paid hospice employees
as well as hospice volunteers, as stated in the August 22, 1983 Hospice
proposed rule (48 FR 38149). This expectation is in line with the
history of hospice and philosophy of holistic, comprehensive,
compassionate, end-of-life care.
The National Hospice Study was initiated in 1980 through a grant
sponsored by the Robert Wood Johnson and John A. Hartford Foundations
and CMS (formerly, the Health Care Financing Administration (HCFA)).
The study was conducted between October 1980 and March 1983. The study
summarized the hospice care philosophy as the following:
Patient and family know of the terminal condition.
Further medical treatment and intervention are indicated
only on a supportive basis.
Pain control should be available to patients as needed to
prevent rather than to just ameliorate pain.
Interdisciplinary teamwork is essential in caring for
patient and family.
Family members and friends should be active in providing
support during the death and bereavement process.
Trained volunteers should provide additional support as
needed.
In the August 22, 1983 Hospice proposed rule (48 FR 38149), we
stated ``the hospice benefit and the resulting Medicare reimbursement
is not intended to diminish the voluntary spirit of hospices''.
D. Medicare Payment for Hospice Care
Sections 1812(d), 1813(a)(4), 1814(a)(7), 1814(i), and 1861(dd) of
the Act, and our regulations in part 418, establish eligibility
requirements, payment standards and procedures, define covered
services, and delineate the conditions a hospice must meet to be
approved for participation in the Medicare program. Part 418, subpart
G, provides for a per diem payment in one of four prospectively-
determined rate categories of hospice care (routine home care,
continuous home care, inpatient respite care, and general inpatient
care), based on each day a qualified Medicare beneficiary is under
hospice care (once the individual has elected it). This per diem
payment is to include all of the hospice services needed to manage the
beneficiaries' care, as required by section 1861(dd)(1) of the Act.
There has been little change in the hospice payment structure since the
benefit's inception. The per diem rate based on level of care was
established in 1983, and this payment structure remains today with some
adjustments, as noted below:
1. Omnibus Budget Reconciliation Act of 1989
Section 6005(a) of the Omnibus Budget Reconciliation Act of 1989
(Pub. L 101-239) amended section 1814(i)(1)(C) of the Act and provided
for the following two changes in the methodology concerning updating
the daily payment rates: (1) Effective January 1, 1990, the daily
payment rates for routine home care and other services in included in
hospice care were increased to equal 120 percent of the rates in effect
on September 30, 1989; and (2) the daily payment rate for routine home
care and other services included in hospice care for fiscal years
beginning on or after October 1, 1990, were the payment rates in effect
during the previous Federal fiscal year increased by the hospital
market basket percentage increase.
2. Balanced Budget Act of 1997
Section 4441(a) of the Balanced Budget Act of 1997 (BBA) (Pub. L
105-33) amended section 1814(i)(1)(C)(ii)(VI) of the Act to establish
updates to hospice rates for FYs 1998 through 2002. Hospice rates were
updated by a factor equal to the hospital market basket percentage
increase, minus 1 percentage point. Payment rates for FYs from 2002
have been updated according to section 1814(i)(1)(C)(ii)(VII) of the
Act, which states that the update to the
[[Page 48238]]
payment rates for subsequent FYs will be the hospital market basket
percentage increase for the FY. The Social Security Act requires us to
use the inpatient hospital market basket to determine hospice payment
rates.
3. FY 1998 Hospice Wage Index Final Rule
In the August 8, 1997 FY 1998 Hospice Wage Index final rule (62 FR
42860), we implemented a new methodology for calculating the hospice
wage index based on the recommendations of a negotiated rulemaking
committee. The original hospice wage index was based on 1981 Bureau of
Labor Statistics hospital data and had not been updated since 1983. In
1994, because of disparity in wages from one geographical location to
another, the Hospice Wage Index Negotiated Rulemaking Committee was
formed to negotiate a new wage index methodology that could be accepted
by the industry and the government. This Committee was comprised of
representatives from national hospice associations; rural, urban, large
and small hospices, and multi-site hospices; consumer groups; and a
government representative. The Committee decided that in updating the
hospice wage index, aggregate Medicare payments to hospices would
remain budget neutral to payments calculated using the 1983 wage index,
to cushion the impact of using a new wage index methodology. To
implement this policy, a BNAF would be computed and applied annually to
the pre-floor, pre-reclassified hospital wage index when deriving the
hospice wage index, subject to a wage index floor.
4. FY 2010 Hospice Wage Index Final Rule
Inpatient hospital pre-floor and pre-reclassified wage index
values, as described in the August 8, 1997 Hospice Wage Index final
rule are subject to either a budget neutrality adjustment or
application of the wage index floor. Wage index values of 0.8 or
greater are adjusted by the budget neutrality adjustment factor (BNAF).
Starting in FY 2010, a 7-year phase-out of the BNAF began (August 6,
2009 FY 2010 Hospice Wage Index final rule (74 FR 39384), with a 10
percent reduction in FY 2010, and additional 15 percent reduction for a
total of 25 percent in FY 2011, an additional 15 percent reduction for
a total 40 percent in FY 2012, and an additional 15 percent reduction
for a total of 55 percent in FY 2013. The phase-out will continue with
an additional 15 percent reduction for a total reduction of 70 percent
in FY 2014, an additional 15 percent reduction for a total reduction of
85 percent in FY 2015, and an additional 15 percent reduction for
complete elimination in FY 2016. We note that the BNAF is an
adjustment, which increases the hospice wage index value. Therefore,
the BNAF reduction is a reduction in the amount of the BNAF increase
applied to the hospice wage index value. It is not a reduction in the
hospice wage index value, or in the hospice payment rates.
5. The Affordable Care Act
Starting with FY 2013 (and in subsequent FYs), the market basket
percentage update under the hospice payment system referenced in
sections 1814(i)(1)(C)(ii)(VII) and 1814(i)(1)(C)(iii) of the Act will
be annually reduced by changes in economy-wide productivity, as
specified in section 1886(b)(3)(B)(xi)(II) of the Act, as amended by
section 3132(a) of the Patient Protection and Affordable Care Act of
2010 (Pub. L. 111-148) as amended by the Health Care and Education
Reconciliation Act of 2010 (Pub. L. 111-152) (the Affordable Care
Act)). In FY 2013 through FY 2019, the market basket percentage update
under the hospice payment system will be reduced by an additional 0.3
percentage point (although for FY 2014 to FY 2019, the potential 0.3
percentage point reduction is subject to suspension under conditions as
specified in section 1814(i)(1)(C)(v) of the Act).
In addition, sections 1814(i)(5)(A) through (C) of the Act, as
amended by section 3132(a) of the Affordable Care Act, require hospices
to begin submitting quality data, based on measures to be specified by
the Secretary, for FY 2014 and subsequent fiscal years. Beginning in FY
2014, hospices which fail to report quality data will have their market
basket update reduced by 2 percentage points.
Section 1814(a)(7)(D)(i) of the Act was amended by section 3132
(b)(2)(D)(i) of the Affordable Care Act, and requires, effective
January 1, 2011, that a hospice physician or nurse practitioner have a
face-to-face encounter with an individual to determine continued
eligibility of the individual for hospice care prior to the 180th-day
recertification and each subsequent recertification and attest that
such visit took place. When implementing this provision, we decided
that the 180th-day recertification and subsequent recertifications
corresponded to the recertification for a beneficiary's third or
subsequent benefit periods (August 4, 2011 FY 2012 Hospice Wage Index
final rule (76 FR 47314)).
Further, section 1814(i)(6) of the Act, as amended by section
3132(a)(1)(B) of the Affordable Care Act, authorizes the Secretary to
collect additional data and information determined appropriate to
revise payments for hospice care and other purposes. The types of data
and information suggested in the Affordable Care Act would capture
accurate resource utilization, which could be collected on claims, cost
reports, and possibly other mechanisms, as the Secretary determines to
be appropriate. The data collected may be used to revise the
methodology for determining the payment rates for routine home care and
other services included in hospice care, no earlier than October 1,
2013, as described in section 1814(i)(6)(D) of the Act. In addition, we
are required to consult with hospice programs and the Medicare Payment
Advisory Commission (MedPAC) regarding additional data collection and
payment revision options.
6. FY 2012 Hospice Wage Index Final Rule
When the Medicare Hospice Benefit was implemented, the Congress
included an aggregate cap on hospice payments, which limits the total
aggregate payments any individual hospice provider can receive in a
year. The Congress stipulated that a ``cap amount'' be computed each
year. The cap amount was set at $6,500 per beneficiary when first
enacted in 1983 and is adjusted annually by the change in the medical
care expenditure category of the consumer price index for urban
consumers from March 1984 to March of the cap year (section
1814(i)(2)(B) of the Act). The cap year is defined as the period from
November 1st to October 31st. As we stated in the August 4, 2011 FY
2012 Hospice Wage Index final rule (76 FR 47308 through 47314), for the
2012 cap year and subsequent cap years, the hospice aggregate cap will
be calculated using the patient-by-patient proportional methodology,
within certain limits. We will allow existing hospices the option of
having their cap calculated via the original streamlined methodology,
also within certain limits. New hospices will have their cap
determinations calculated using the patient-by-patient proportional
methodology. The patient-by-patient proportional methodology and the
streamlined methodology are two different methodologies for counting
beneficiaries when calculating the hospice aggregate cap. A detailed
explanation of these methods is found in the August 4, 2011 FY 2012
Hospice Wage Index final rule (76 FR 47308 through 47314). If a
hospice's total
[[Page 48239]]
Medicare reimbursement for the cap year exceeded the hospice aggregate
cap, then the hospice would have to repay the excess back to Medicare.
E. Trends in Medicare Hospice Utilization
Since the implementation of the hospice benefit in 1983, and
especially within the last decade, there has been substantial growth in
hospice utilization. The number of Medicare beneficiaries receiving
hospice services has grown from 513,000 in FY 2000 to over 1.3 million
in FY 2012. Similarly, Medicare hospice expenditures have risen from
$2.9 billion in FY 2000 to $14.7 billion in FY 2012. Our Office of the
Actuary (OACT) projects that hospice expenditures are expected to
continue to increase by approximately 8 percent annually, reflecting an
increase in the number of Medicare beneficiaries, more beneficiary
awareness of the Medicare Hospice Benefit for end-of-life care, and a
growing preference for care provided in home and community-based
settings. However, this increased spending is partly due to an
increased average lifetime length of stay for beneficiaries, from 54
days in 2000 to 86 days in FY 2010, an increase of 59 percent.
There have also been noted changes in the diagnosis patterns among
Medicare hospice enrollees, with a growing percentage of beneficiaries
with non-cancer diagnoses. Specifically, there were notable increases
between 2002 and 2007 in neurologically-based diagnoses, including
various dementia diagnoses. Additionally, there have been significant
increases in the use of non-specific, symptom-classified diagnoses,
such as ``debility'' and ``adult failure to thrive.'' In FY 2012, both
``debility'' and ``adult failure to thrive'' were in the top five
claims-reported hospice diagnoses and were the first and third most
common hospice diagnoses, respectively (see Table 2 below).
Table 2--The Top Twenty Principal Hospice Diagnoses, FY 2002, FY 2007, FY 2012
----------------------------------------------------------------------------------------------------------------
Rank ICD-9/Reported principal diagnosis Total patients Percentage
----------------------------------------------------------------------------------------------------------------
Year: 2002 Total Patients = 663,406
----------------------------------------------------------------------------------------------------------------
1....................................... 162.9 Lung Cancer................. 73,769 11
2....................................... 428.0 Congestive Heart Failure.... 45,951 7
3....................................... 799.3 Debility Unspecified........ 36,999 6
4....................................... 496 COPD.......................... 35,197 5
5....................................... 331.0 Alzheimer's Disease......... 28,787 4
6....................................... 436 CVA/Stroke.................... 26,897 4
7....................................... 185 Prostate Cancer............... 20,262 3
8....................................... 783.7 Adult Failure To Thrive..... 18,304 3
9....................................... 174.9 Breast Cancer............... 17,812 3
10...................................... 290.0 Senile Dementia, Uncomp..... 16,999 3
11...................................... 153.0 Colon Cancer................ 16,379 2
12...................................... 157.9 Pancreatic Cancer........... 15,427 2
13...................................... 294.8 Organic Brain Synd Nec...... 10,394 2
14...................................... 429.9 Heart Disease Unspecified... 10,332 2
15...................................... 154.0 Rectosigmoid Colon Cancer... 8,956 1
16...................................... 332.0 Parkinson's Disease......... 8,865 1
17...................................... 586 Renal Failure Unspecified..... 8,764 1
18...................................... 585 Chronic Renal Failure (End 8,599 1
2005).
19...................................... 183.0 Ovarian Cancer.............. 7,432 1
20...................................... 188.9 Bladder Cancer.............. 6,916 1
----------------------------------------------------------------------------------------------------------------
Year: 2007 Total Patients = 1,039,099
----------------------------------------------------------------------------------------------------------------
1....................................... 799.3 Debility Unspecified........ 90,150 9
2....................................... 162.9 Lung Cancer................. 86,954 8
3....................................... 428.0 Congestive Heart Failure.... 77,836 7
4....................................... 496 COPD.......................... 60,815 6
5....................................... 783.7 Adult Failure To Thrive..... 58,303 6
6....................................... 331.0 Alzheimer's Disease......... 58,200 6
7....................................... 290.0 Senile Dementia Uncomp...... 37,667 4
8....................................... 436 CVA/Stroke.................... 31,800 3
9....................................... 429.9 Heart Disease Unspecified... 22,170 2
10...................................... 185 Prostate Cancer............... 22,086 2
11...................................... 174.9 Breast Cancer............... 20,378 2
12...................................... 157.9 Pancreas Unspecified........ 19,082 2
13...................................... 153.9 Colon Cancer................ 19,080 2
14...................................... 294.8 Organic Brain Syndrome NEC.. 17,697 2
15...................................... 332.0 Parkinson's Disease......... 16,524 2
16...................................... 294.10 Dementia In Other Diseases 15,777 2
w/o Behav. Dist..
17...................................... 586 Renal Failure Unspecified..... 12,188 1
18...................................... 585.6 End Stage Renal Disease..... 11,196 1
19...................................... 188.9 Bladder Cancer.............. 8,806 1
20...................................... 183.0 Ovarian Cancer.............. 8,434 1
----------------------------------------------------------------------------------------------------------------
Year: 2012 Total Patients = 1,328,651
----------------------------------------------------------------------------------------------------------------
1....................................... 799.3 Debility Unspecified........ 161,163 12
2....................................... 162.9 Lung Cancer................. 89,636 7
3....................................... 783.7 Adult Failure To Thrive..... 86,467 7
4....................................... 428.0 Congestive Heart Failure.... 84,333 6
[[Page 48240]]
5....................................... 496 COPD.......................... 74,786 6
6....................................... 331.0 Alzheimer's Disease......... 64,199 5
7....................................... 290.0 Senile Dementia, Uncomp..... 56,234 4
8....................................... 429.9 Heart Disease Unspecified... 32,081 2
9....................................... 436 CVA/Stroke.................... 31,987 2
10...................................... 294.10 Dementia In Other Diseases 27,417 2
w/o Behavioral Dist..
11...................................... 174.9 Breast Cancer............... 22,421 2
12...................................... 153.9 Colon Cancer................ 22,197 2
13...................................... 157.9 Pancreatic Cancer........... 22,007 2
14...................................... 332.0 Parkinson's Disease......... 21,183 2
15...................................... 185 Prostate Cancer............... 21,042 2
16...................................... 294.8 Other Persistent Mental Dis.- 17,762 1
classified elsewhere.
17...................................... 585. 6 End Stage Renal Disease.... 17,545 1
18...................................... 518.81 Respiratory Failure........ 12,962 1
19...................................... 294.11 Dementia In Other Diseases 11,751 1
w/Behavioral Dist..
20...................................... 188.9 Bladder Cancer.............. 10,511 1
----------------------------------------------------------------------------------------------------------------
Source: FY 2002, 2007, and 2012 hospice claims data from the Chronic Conditions Warehouse (CCW), accessed on
February 14 and February 20, 2013.
Note(s): The frequencies shown represent beneficiaries that had a least one claim with the specific ICD-9 code
reported as the principal diagnosis. Beneficiaries could be represented multiple times in the results if they
have multiple claims during that time period with different principal diagnoses.
III. Summary of the Provisions of the Proposed Rule
The May 10, 2013 FY 2014 hospice proposed rule (78 FR 27823)
included the following clarifications, proposals, and updates:
Diagnosis reporting on claims;
Proposed update to the Hospice Quality Reporting Program;
FY 2014 Rate Update;
Update on Hospice Payment Reform and Data Collection; and
Technical and Clarifying Regulations Text Change.
A. Diagnosis Reporting on Claims
The FY 2014 Hospice Wage Index and Payment Rate Update proposed
rule clarified appropriate diagnosis reporting on hospice claims. No
proposals were made regarding diagnosis coding. These clarifications
are not to preclude any clinical judgment in determining a
beneficiary's eligibility for hospice services. Eligibility for hospice
services is based on meeting the eligibility requirements as stated in
Sec. 418.20 of our regulations: ``an individual must be--
(a) Entitled to Part A of Medicare; and
(b) Certified as being terminally ill in accordance with Sec.
418.22.''
1. ICD-9-CM Coding Guidelines
The hospice benefit covers all care for the terminal illness,
related conditions, and for the management of pain and symptoms. HIPAA,
federal regulations, and the Medicare hospice claims processing manual
all require that ICD-9-CM Coding Guidelines be applied to the coding
and reporting of diagnoses on hospice claims. Regarding diagnosis
reporting on hospice claims, we clarified in our July 27, 2012 FY 2013
Hospice Wage Index notice (77 FR 44247 through 44248) that all
providers are required to code and report the principal diagnosis as
well as all coexisting and additional diagnoses related to the terminal
condition or related conditions to more fully describe the Medicare
patients they are treating.
2. Use of Nonspecific Symptom Diagnoses
The proposed rule included additional diagnosis clarifications to
address current and ongoing diagnosis reporting patterns noted on
hospice claims, more specifically the use of nonspecific, symptom
diagnoses and certain dementia diagnoses. In the proposed rule, we
clarified that the ICD-9-CM codes of ``debility'' and ``adult failure
to thrive'' listed in the ICD-9-CM Coding Guidelines under the
classification, ``Symptoms, Signs, and Ill-defined Conditions'', are
not to be used as principal diagnoses when a related definitive
diagnosis has been established or confirmed by the provider. Therefore,
in the proposed rule, we clarified that ``debility'' and ``adult
failure to thrive'' should not be used as principal hospice diagnoses
on the hospice claim form. When reported as a principal diagnosis,
these would be considered questionable encounters for hospice care, and
the claim would be returned to the provider for a more definitive
principal diagnosis. ``Debility'' and ``adult failure to thrive'' could
be reported on the hospice claim as other, additional, or coexisting
diagnoses. The principal diagnosis reported should be the condition
determined by the certifying hospice physician(s) as the diagnosis most
contributory to the terminal decline.
3. Use of ``Mental, Behavioral and Neurodevelopmental Disorders'' ICD-
9-CM Codes
The proposed rule also clarified the ICD-9-CM Coding Guidelines for
certain dementia codes that are reported on hospice claims. There are
several, but not all, codes that fall under the classification,
``Mental, Behavioral and Neurodevelopmental Disorders,'' that encompass
multiple dementia diagnoses that are frequently reported principal
hospice diagnoses on hospice claims, but are not appropriate principal
diagnoses per ICD-9-CM Coding Guidelines.
4. Guidance on Coding of Principal and Other, Additional, and/or Co-
Existing Diagnoses
In the proposed rule, we reiterated that diagnosis reporting on the
hospice claims should include the appropriate selection of principal
diagnoses as well as the other, additional and coexisting diagnoses
related to the terminal illness. In the July 27, 2012 FY 2013 Hospice
Wage Index notice (77 FR 44247), we provided in-depth information
regarding longstanding, existing ICD-9-CM Coding Guidelines. We also
discussed related versus unrelated diagnosis reporting on claims and
clarified that ``all of a patient's coexisting or additional
diagnoses'' related to the terminal illness or related conditions
should be reported on the hospice claim. Based on analysis of
preliminary claims data from the first quarter of FY 2013 (October 1,
2012 through December 31, 2012), 72 percent
[[Page 48241]]
of providers still only report one diagnosis on the hospice claim. This
hospice diagnosis data is comparable to the hospice diagnosis data
reported in the July 27, 2012 FY 2013 Hospice Wage Index notice (77 FR
44242), in which we stated that over 77 percent of the hospice claims
reported only a principal diagnosis.
Information on a patient's related and unrelated diagnoses should
already be included as part of the hospice comprehensive assessment and
appropriate interventions for the palliation and management of the
terminal illness and related conditions should be incorporated into the
patient's plan of care, as determined by the hospice interdisciplinary
group (IDG).
5. Transition to ICD-10-CM
The proposed rule reminded the hospice industry that ICD-10-CM will
replace the ICD-9-CM on October 1, 2014. A critical issue associated
with the transition to ICD-10-CM involves the matter of crosswalking
between the ICD-9-CM and ICD-10-CM code sets. The term ``crosswalking''
is generally defined as the act of mapping or translating a code in one
code set to a code or codes in another code set. (The terms
``crosswalking'' and ``mapping'' are sometimes used interchangeably.)
Understanding crosswalking will be important to physicians during the
transition phase when learning which new ICD-10 code to use in place of
an ICD-9 code. We provided information regarding the crosswalks from
ICD-9-CM to ICD-10-CM and this information is available for free and
can be downloaded from the NCHS Web site, www.cdc.gov/nchs/icd/icd10cm.htm. Hospices should not substitute crosswalking for learning
and fully implementing ICD-10-CM into their procedures. Additional
information regarding the transition to ICD-10-CM is available through
the CMS Web site at: https://www.cms.gov/Medicare/Coding/ICD10/?redirect=/icd10.
B. Hospice Quality Reporting Program
We proposed to eliminate two currently reported measures,
the structural measure related to Quality Assurance and Performance
Improvement (QAPI) and the NQF 0209 pain measure, and we
offered an alternate proposal to retain the currently reported NQF
0209 pain measure until a suitable comfort outcome measure is
available as described in section III.B.3 of the FY 2014 hospice wage
index and payment update proposed rule (78 FR 27835);
We proposed to implement the Hospice Item Set (HIS), a
standardized patient-level data collection vehicle, effective 7/1/2014
and to utilize the seven NQF-endorsed measures derived from the HIS in
the hospice quality reporting program as described in section III.B.4
of the FY 2014 hospice wage index and payment update proposed rule (78
FR 27836); and
We proposed that hospices begin national implementation of
the Hospice Experience of Care Survey by participating in a dry run in
January 2015 through March 2015, and then, beginning in April 2015,
conduct monthly implementation of the survey through December 2015 to
meet the requirements of the 2017 annual payment update as described in
section III.B.6 of the FY 2014 hospice wage index and payment update
proposed rule (78 FR 27837).
C. FY 2014 Hospice Wage Index and Rates Update
The proposed updates to the hospice rates for FY 2014 are as
follows:
Update the hospice wage index using the 2013 pre-floor,
pre-reclassified hospital wage index as discussed in section III.C.1 of
the FY 2014 hospice wage index and rate update proposed rule (78 FR
27839);
Update the hospice wage index taking into account the
application of the hospice floor or budget neutrality adjustment factor
reduced an additional 15 percent, for a BNAF phase-out of 70 percent as
finalized in the FY 2010 hospice wage index final rule (74 FR 39384),
as discussed in section III.C.2 of the FY 2014 hospice wage index and
rate update proposed rule (78 FR 27840); and
Apply the hospice payment update percentage, as discussed
in section III.C.3 of the FY 2014 hospice wage index and rate update
proposed rule, to the FY 2013 hospice payment rates as discussed in
section III.C.4 of the FY 2014 hospice wage index and rate update
proposed rule (78 FR 27841 through 27842).
D. Update on Hospice Payment Reform and Data Collection
We did not make any payment reform proposals or solicit comments on
this section, but included updates and a discussion of payment reform
activities, including:
A discussion of reform options, including the U-shaped
curve model, a tiered model that uses the U-shaped curve, a short-stay
add-on payment, and case-mix adjustment.
A discussion of rebasing a portion of the routine home
care (RHC) payment rate; adjusting for current costs would reduce the
FY 2014 RHC rate by 10.1 percent.
A discussion of the Office of Inspector General (OIG) and
MedPAC recommendations to reduce payments to hospices for RHC patients
in nursing facilities, to account for duplication of aide services. The
claims visit data on aide services revealed that hospice patients in
nursing facilities receiving more visits, but shorter visits than
patients at home; however, on average, hospice patients in nursing
facilities receive 22 percent more minutes of aide care than hospice
patients at home.
A discussion of reform research findings related to cost
reports and general inpatient care (GIP), and a link to the Abt Hospice
Study Technical Report and an Abt review of the literature.
A summary of comments received from a December, 2012 CMS
Web site posting about additional data collection on hospice claims; a
forthcoming Change Request will finalize the data collection this
summer.
An update on the status of the hospice cost report
revisions, which were published as part of a Paperwork Reduction Act
notice in the Federal Register on April 29, 2013.
E. Technical and Clarifying Regulations Text Change
We proposed a technical change to correct an erroneous cross
reference in our regulations text at Sec. 418.311, as discussed in
section III.E of the FY 2014 Hospice Wage Index and Rate Update
proposed rule (78 FR 27847).
IV. Analysis and Responses to Public Comments
We received approximately 125 comments, many of which contained
multiple comments, on the FY 2014 hospice wage index and payment rate
update proposed rule. We received comments from various trade
associations, private insurers, individual hospices, hospitals,
physicians, medical directors, nurses, visiting nurses associations,
home health agencies, hospice volunteers, and individuals. We
appreciate the numerous thoughtful and insightful comments received and
believe that communication and collaboration between CMS and all
hospice stakeholders is imperative. The comments received and our
responses to these comments are grouped by subject area and are
summarized below.
[[Page 48242]]
A. Diagnosis Reporting on Hospice Claims
We made no new proposals regarding ICD-9-CM Coding Guidelines in
the FY 2014 Hospice Wage Index and Payment Rate Update proposed rule.
However, we did make clarifications regarding ICD-9-CM Coding
Guidelines for the selection of principal diagnoses and additional
diagnoses. These clarifications are not to preclude any clinical
judgment in determining a beneficiary's eligibility for hospice
services. Eligibility for hospice services is based on meeting the
eligibility requirements as stated in Sec. 418.20 of our regulations:
``. . . an individual must be--
(a) Entitled to Part A of Medicare; and
(b) Certified as being terminally ill in accordance with Sec.
418.22.''
Specifically, we clarified the following:
``Debility'' or ``adult failure to thrive'' should not be
used as a principal hospice diagnosis on the hospice claim form per
ICD-9-CM Coding Guidelines. ``Debility'' and/or ``adult failure to
thrive'' may be used as another, additional, or coexisting diagnosis on
the hospice claim form. If ``debility'' or ``adult failure to thrive''
is reported as the principal diagnosis on the hospice claim forms,
these claims will be returned to the provider for more definitive
coding.
Dementia codes classified under ``Mental, Behavioral and
Neurodevelopmental Disorders'' are among the top twenty hospice claims
reported diagnoses. Many of these codes are not appropriate as
principal diagnoses because of manifestation/etiology guidelines or
sequencing conventions under the ICD-9-CM Coding Guidelines. Particular
attention must be paid to dementia diagnoses which are found under two
separate ICD-9-CM classifications: ``Mental, Behavioral, and
Neurodevelopmental Disorders'' and ``Diseases of the Nervous System and
Sense Organs.'' There are also dementia codes that are classified under
``Diseases of the Nervous System and Sense Organs'' that also have
sequencing conventions and, therefore, are not appropriate as principal
diagnoses on the hospice claim.
We provided ICD-9-CM coding guidance regarding the coding
of principal and other, additional, and/or coexisting diagnoses. The
principal diagnosis should reflect the condition to be chiefly
responsible for the services provided. ICD-9-CM Coding Guidelines
specify that the circumstances of an inpatient hospital admission
diagnosis are to be used in determining the selection of a principal
diagnosis. ICD-9-CM Coding Guidelines also state to ``code all
documented conditions at the time of the encounter/visit, and require
or affect patient care treatment or management.'' The principal
diagnosis reported on the hospice claim form should be determined by
the hospice as the diagnosis most contributory to the terminal
prognosis.
Hospice providers are expected to report all coexisting or
additional diagnoses related to the terminal illness and related
conditions on the hospice claim to be in compliance with existing
policy, and provide data needed for evaluating potential hospice
payment reform methodologies.
We reminded providers of the transition to ICD-10-CM,
which will replace ICD-9-CM on October 1, 2014.
Crosswalking from ICD-9-CM to ICD-10-CM is important for
providers in understanding the transition between these two code sets.
We received 109 comments on diagnosis reporting on hospice claims,
which are summarized below according to subsection.
1. ICD-9-CM Coding Guidelines
The hospice benefit covers all care for the terminal illness and
related conditions, including the management of pain and symptoms.
HIPAA, federal regulations, and the Medicare hospice claims processing
manual all require that ICD-9-CM Coding Guidelines be applied to the
coding and reporting of diagnoses on hospice claims. Regarding
diagnosis reporting on hospice claims, we clarified in our July 27,
2012 FY 2013 Hospice Wage Index notice (77 FR 44247 through 44248) that
all providers should code and report the principal diagnosis as well as
all coexisting and additional diagnoses related to the terminal
condition or related conditions to more fully describe the Medicare
patients they are treating.
Comment: Several commenters expressed concern that the coding
clarification would require that hospices have a professional coder for
coding claims, which would create a financial burden on hospice
providers. Some commenters believed that we were asking hospices to
hire professional coders. Other commenters thought that we were asking
physicians to spend time determining the proper ICD-9-CM code for the
claim.
Response: We did not state in the FY 2014 hospice wage index and
payment update proposed rule that any hospice provider would be
expected or required to have a professional coder to complete the
coding on the hospice claims. Our discussion of the coding guidelines
in the proposed rule was to assist hospice providers in complying with
longstanding policies. In our regulations at 45 CFR 162.1002, the
Secretary adopted the ICD-9-CM code set, including The Official ICD-9-
CM Guidelines for Coding and Reporting. The CMS' Hospice Claims
Processing Manual (Pub 100-04, chapter 11) requires that hospice claims
include other diagnoses ``as required by ICD-9-CM Coding Guidelines''.
In the proposed rule, we provided guidance from the ICD-9-CM Official
Guidelines for Coding and Reporting to highlight coding guidelines for
principal and other diagnosis selection, as well as the various coding
and sequencing conventions found therein. This clarification of the
coding guidelines was in response to the monitoring of diagnostic
reporting patterns noted on hospice claims, especially in regards to
the reporting of only one diagnosis and the use of diagnoses not
appropriate as principal diagnoses per the ICD-9-CM Coding Guidelines.
We believe there are ample, available resources in regards to the ICD-
9-CM Coding Guidelines to support hospice providers who choose not to
have a professional coder complete their hospice claims, including the
links provided within the proposed rule. These free resources are
available at the following links: https://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/?redirect=/ICD9ProviderDiagnosticCodes/, https://www.cms.gov/medicare-coverage-database/staticpages/icd-9-code-lookup.aspx, or on the CDC's Web site
at: https://www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2011.pdf.
Additionally, more information regarding guidance for hospice
claims coding can be found in the CMS' Hospice Claims Processing manual
(Pub 100-04, chapter 11) available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c11.pdf. Finally, while
hospice physicians use their clinical judgment to determine the
principal diagnosis and related conditions, we do not require them to
determine to the actual codes associated with those diagnoses for
inclusion on the hospice claim. Hospices have the flexibility to
determine how to take the physicians' information about diagnoses and
translate it into the appropriate codes on the claim.
2. Use of Non-Specific, Symptom Diagnoses
The proposed rule included additional diagnosis clarifications to
address current and ongoing diagnosis
[[Page 48243]]
reporting patterns noted on hospice claims, more specifically the use
of nonspecific, symptom diagnoses and certain dementia diagnoses. In
the proposed rule, we clarified that the ICD-9-CM codes of ``debility''
and ``adult failure to thrive'' are listed in the ICD-9-CM Coding
Guidelines under the classification, ``Symptoms, Signs, and Ill-defined
Conditions'', and are not to be used as principal diagnoses when a
related definitive diagnosis has been established or confirmed by the
provider. Therefore, in the proposed rule, we clarified that
``debility'' and ``adult failure to thrive'' should not be used as
principal hospice diagnoses on the hospice claim form. When reported as
a principal diagnosis, these would be considered questionable
encounters for hospice care, and the claim would be returned to the
provider for a more definitive principal diagnosis. ``Debility'' and
``adult failure to thrive'' could be reported on the hospice claim as
other, additional, or coexisting diagnoses. The principal diagnosis
reported should be the condition determined by the certifying hospice
physician(s) as the diagnosis most contributory to the terminal
decline.
Comment: We received numerous comments in support of or
acknowledging the need for these diagnostic clarifications and
enforcement of existing coding guidelines. Several commenters
acknowledged understanding the need to identify a principal hospice
diagnosis when a patient has multiple diagnoses instead of using
``debility'' or ``adult failure to thrive.'' Another commenter stated
that their hospice program has tried to avoid the use of ``debility''
as a principal hospice diagnosis and agreed that this diagnosis has
been over-used nationally; several commenters acknowledged that there
has been ``sloppy diagnosing'' with the use of ``debility'' and ``adult
failure to thrive.'' One commenter stated that the use of ``debility''
or ``adult failure to thrive'' is most often a ``failure to diagnose.''
One commenter stated that ``debility'' cannot be reported as a cause of
the death on a death certificate in his state and that he had to select
a different diagnosis for an immediate cause of death as well as a
secondary, longer-term related cause. Several commenters asked what to
expect regarding the application of the Local Coverage Determination
(LCD) guidelines provided by the Home Health and Hospice Medicare
Administrative Contractors.
Response: We appreciate that some hospice providers are recognizing
the issues regarding the inappropriate use of ``debility'' or ``adult
failure to thrive'' as a principal hospice diagnosis reported on the
hospice claim and are attempting to take steps to more fully describe
their patient populations. We will continue to work with our Home
Health and Hospice contractors to ensure that all LCDs will reflect
these principal hospice diagnostic coding clarifications and that those
eligible Medicare hospice beneficiaries will continue to have access to
the benefits of hospice care. This collaboration will not be limited to
the release of Change Requests, which can be found on our hospice Web
site at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Hospice-Transmittals.html. Additionally, we encourage all
interested stakeholders to participate in the CMS Home Health and
Hospice Open Door Forums where questions, concerns and issues can be
addressed with specialists within CMS. Information regarding Open Door
Forums can be found on our Web site at https://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/.
Comment: There were a number of commenters who expressed concern
that no longer allowing the use of ``debility'' or ``adult failure to
thrive'' as a principal hospice diagnosis would limit or prohibit
access to hospice care for Medicare beneficiaries. Commenters stated
that by not allowing these two diagnoses to be coded as a principal
hospice diagnosis, they believed that beneficiaries would elect hospice
later in their disease trajectories. Other commenters felt that
eligible beneficiaries would not be admitted to hospice care at all
because a single definitive terminal diagnosis could not be determined
by the certifying physician. Other commenters stated that it is
difficult to determine a single principal terminal diagnosis for
beneficiaries with multiple chronic or coexisting conditions.
Response: Patient-centered care is at the core of the Medicare
hospice benefit. Our mission is to be effective stewards of public
funds, and we are committed to strengthening and modernizing the
nation's health care system to provide access to high quality care. We
believe that Medicare beneficiaries who are approaching end-of-life are
at their most vulnerable state and should be afforded the most
comprehensive and responsible clinical judgment. Medicare beneficiaries
who are hospice eligible should be fully informed by their health care
providers, including hospice providers, as to their conditions
contributing to their terminal decline and their treatment options for
ongoing care. We are aware that diagnosing diseases and determining
prognosis is not always a perfect science. Certifying physicians should
use their best clinical judgment in determining the principal diagnosis
and related conditions, based on the hospice comprehensive assessment
and review of any and all other clinical documentation.
It remains our belief that the goal of hospice care is to provide
comprehensive, holistic, and individualized services to eligible
Medicare beneficiaries. In order to receive these comprehensive hospice
services, Medicare beneficiaries must be certified as terminally ill.
This certification is based on the recommendation of the medical
director in consultation with, or with input from, the beneficiary's
attending physician (if any) and a comprehensive assessment of all body
systems. The hospice regulations require that this certification be
based on a variety of factors when making the clinical determination
that a patient has a life expectancy of 6 months or less, should the
illness run its normal course. The regulations in Sec. 418.25(b),
Admission to hospice care, state, ``In reaching a decision to certify
that the patient is terminally ill, the hospice medical director must
consider at least the following information:
Diagnosis of the terminal condition of the patient.
Other health conditions, whether related or unrelated to
the terminal condition.
Current clinical relevant information supporting all
diagnoses.''
Based on this certification and the Medicare beneficiary's election
of the hospice benefit, initial and ongoing comprehensive assessments
are conducted to establish and maintain the hospice plan of care. A
comprehensive hospice plan of care starts with accurate and thorough
assessment and identification of the conditions (including diseases and
symptoms) contributing to the terminal prognosis. This comprehensive
plan of care is to include all the services and care needed for the
management and palliation of the terminal illness and related
conditions. This hospice plan of care is to include the following, per
the Hospice Conditions of Participation:
Interventions to manage pain and symptoms;
A detailed statement of the scope and frequency of
services necessary to meet the specific patient and family needs;
Measurable outcomes anticipated from implementing and
coordinating the plan of care;
[[Page 48244]]
Drugs and treatment necessary to meet the needs of the
patient;
Medical supplies and appliances to meet the needs of the
patient; and,
The interdisciplinary group's documentation of the
patient's or representative's level of understanding, involvement, and
agreement with the plan of care, in accordance with the hospice's own
policies, in the clinical record (Sec. 418.56(c)).
A hallmark clinical characteristic of both ``debility'' and ``adult
failure to thrive'' is the presence of multiple primary conditions.
According to ICD 9 Coding Guidelines, codes that fall under the
classification ``Symptoms, Signs, and other Ill-defined Conditions'',
such as ``debility'' and ``adult failure to thrive'', can only be used
as a principal diagnosis when a related definitive diagnosis has not
been established or confirmed by the provider. The individual diagnosed
with ``debility'' or ``adult failure to thrive'' may have multiple
comorbid conditions that individually, may not deem the individual to
be terminally ill. However, the collective presence of these multiple
comorbid conditions will contribute to the terminal prognosis of the
individual. Additionally, Medicare beneficiaries waive their right to
Medicare payment for curative treatments under the Medicare Hospice
Benefit; hospice providers are clinically and ethically responsible for
ensuring that eligible Medicare beneficiaries are made fully aware of
all of the conditions contributing to their terminal decline so they
can make the informed decision as to which treatment approaches they
would like to pursue.
As ``debility'' and ``adult failure to thrive'' are nonspecific,
ill-defined, symptom diagnoses, they should not be reported as
principal diagnosis. Rather, the condition that the hospice medical
director determines is most contributory to the terminal prognosis
should be reported as the principal diagnosis on the hospice claim and
all other related conditions to the terminal prognosis should be
reported as additional diagnoses. Therefore, the claim should include
not only a principal diagnosis, but all other related diagnoses as
well, to more fully describe the clinical picture of the terminally ill
individual. In fact, reporting all of the related conditions that are
contributing to the terminal prognosis on the hospice claim may also
further support the eligibility for hospice services. Therefore, we do
not believe that these coding clarifications will or should create any
limitations or barriers to accessing Medicare hospice services by
eligible Medicare beneficiaries, as coding on claims occurs after the
beneficiary is fully informed and has chosen to elect and access
hospice services. In fact, adherence to the ICD-9-CM Coding Guidelines
should promote access to appropriate and comprehensive hospice
services. Medicare beneficiaries should always expect the right care at
the right time and care that best suits their individual clinical
status as well as their treatment preferences. Further, some medical
experts have argued that these non-specific, ill-defined terms should
be abandoned because they do not assist in the thoughtful evaluation of
patients who may have treatable, underlying conditions.\4\ We are
clarifying these coding guidelines so that hospice providers can be
more intentional about addressing all of the beneficiary's identified
needs as he or she approaches end-of-life. One physician commenter
stated that he reviews old records, calls attending physicians, and
uses professional judgment to thoughtfully evaluate his patients for
hospice care.
---------------------------------------------------------------------------
\4\ Pacala, J.T., Sullivan, G.M. eds. Geriatrics Review
Syllabus: A Core Curriculum in Geriatric Medicine. 7th ed. New York:
American Geriatrics Society; 2010.
---------------------------------------------------------------------------
Analysis conducted by our hospice payment reform contractor, Abt
Associates, of Medicare hospice beneficiaries with ``debility'' or
``adult failure to thrive'' reported as their principal hospice
diagnosis, but no reported secondary diagnoses in FY 2012 revealed that
over 50 percent of these hospice beneficiaries had seven or more
chronic conditions and 75 percent had four or more chronic conditions
as identified in the Chronic Condition Data Warehouse. The Chronic
Condition Data Warehouse is a research database that includes Medicare,
Medicaid assessments and Part D drug event data to support research
designed to improve the quality of care and reduce cost and
utilization. These chronic conditions include: Alzheimer's disease,
non-Alzheimer's dementia, senile degeneration of the brain, congestive
heart failure, chronic obstructive pulmonary disease, ischemic heart
disease, chronic kidney disease, and various cancer diagnoses. While
these conditions are labeled as chronic, many of these are often
terminal conditions as well, while others are contributory to the
terminal prognosis of the individual. See Table 3 below:
Table 3--Chronic Conditions of Those Beneficiaries With ``Debility'' or
``Adult Failure To Thrive'' Reported as Principal Hospice Diagnosis but
With No Secondary Diagnoses Reported, FY 2012
------------------------------------------------------------------------
Percent
------------------------------------------------------------------------
Percent of Beneficiaries with Anemia................. 76
Percent of Beneficiaries with Alzheimer's Disease and 66
Related Disorders or Senile Dementia................
Percent of Beneficiaries with Rheumatoid Arthritis/ 66
Osteoarthritis......................................
Percent of Beneficiaries with Ischemic Heart Disease. 63
Percent of Beneficiaries with Depression............. 55
Percent of Beneficiaries with Heart Failure.......... 53
Percent of Beneficiaries with Chronic Kidney Disease. 43
Percent of Beneficiaries with Chronic Obstructive 39
Pulmonary Disease and Bronchiectasis................
Percent of Beneficiaries with Osteoporosis........... 39
Percent of Beneficiaries with Alzheimer's Disease.... 38
Percent of Beneficiaries with Stroke................. 34
Percent of Beneficiaries with Atrial Fibrillation.... 28
Percent of Beneficiaries with Hip/Pelvic Fracture.... 20
Percent of Beneficiaries with Asthma................. 13
Percent of Beneficiaries with Acute Myocardial 9
Infarction..........................................
Percent of Beneficiaries with Breast Cancer.......... 7
Percent of Beneficiaries with Prostate Cancer........ 5
Percent of Beneficiaries with Colorectal Cancer...... 5
Percent of Beneficiaries with Lung Cancer............ 2
[[Page 48245]]
Percent of Beneficiaries with Endometrial Cancer..... 1
------------------------------------------------------------------------
Source: FY 2012 hospice claims data from Chronic Conditions Warehouse
(CCW), accessed on June 27, 2013. N = 184,924 hospice beneficiaries
with principal diagnosis of ``debility'' or ``adult failure to
thrive'' with no reported secondary diagnoses on the hospice claim.
Comment: Several commenters stated that ``Debility'' is an
allowable principal diagnosis under ICD-9-CM Coding Guidelines if there
is no established or confirmed definitive diagnosis.
Response: While the ICD-9-CM Coding Guidelines state ``codes that
describe symptoms, signs, as opposed to diagnoses, are acceptable for
reporting purposes when a related definitive diagnosis has not been
established (confirmed) by the provider,'' we believe that in
encompassing the true nature of the holistic hospice philosophy, these
ill-defined diagnoses are not appropriate as the principal diagnosis on
the hospice claim where an individual has typically had multiple health
care encounters that have eventually led to their election of hospice
services and physician certification as being terminally ill. In the FY
2014 Hospice Wage Index and Payment Rate Update proposed rule (78 FR
27831), we clarified that if any or all of these multiple primary
conditions (as characterized under ``debility'' and ``adult failure to
thrive'') have been or are being treated, or if medications have been
prescribed for the patient to treat or manage any or all of these
multiple primary conditions, we believe that these conditions meet the
criteria of being established and/or confirmed by the beneficiary's
health care provider and, thus, ``debility'' or ``adult failure to
thrive'' would not be appropriate as the principal hospice diagnosis
per ICD-9-CM Coding Guidelines. For those beneficiaries who have not
had multiple health care encounters prior to hospice election, it is
that much more important that certifying physicians make a thoughtful
evaluation of all of the conditions contributing to an individual's
terminal prognosis. The physician is responsible for making sure that
the individual electing hospice care is fully aware of all treatment
options available in order for that individual to make the most
informed treatment decisions.
Comment: Several commenters noted that hospice eligibility is based
on the prognosis and not the diagnosis, and some expressed concern as
to why CMS is so focused on the diagnosis.
Response: To address the comments regarding the focus on diagnosis
rather than prognosis, eligibility for hospice services under the
Medicare Hospice Benefit has always been based on the prognosis of the
individual, not diagnosis, since the implementation of the Medicare
Hospice Benefit in 1983. As stated in the proposed rule on August 22,
1983, ``The regulations would specify, consistent with the requirements
of sections 1812 and 1814(a)(8) of the Act, that to be eligible for
Medicare coverage of hospice care, an individual must be entitled to
Medicare Part A, and must be certified as terminally ill'' (48 FR
38147). These criteria have not changed, and we believe that all
eligible individuals will continue to have access to the Medicare
Hospice Benefit. However, certifications and recertifications of
hospice eligibility are statutory requirements for coverage and
payment. The content of the certifications and recertifications must
conform to the following requirements at Sec. 418.22(b), Content of
certification. These requirements include, but are not limited to the
following:
The certification must specify that the individual's
prognosis is for a life expectancy of six months or less if the
terminal illness runs its normal course.
Clinical information and other documentation that support
the medical prognosis must be in the medical record with the written
certification.
The physician must include a brief narrative explanation
of the clinical findings that supports a life expectancy of 6 months or
less as part of the certification and recertification forms or as an
addendum to these forms. On hospice claims however, we are not seeing
the level of completeness of diagnosis reporting as is required for the
certification and recertifications. As stated in the proposed rule,
data analysis of preliminary hospice claims data from the first quarter
of FY 2013 (October 1, 2012 through December 31, 2012) showed that over
72 percent of providers only report one diagnosis on the hospice claim.
Further, analysis of third quarter FY 2013 data (April 1, 2013 through
June 30, 2013 as of July 1, 2013) showed that 69 percent of providers
still only report one diagnosis on the hospice claim. The hospice
claims processing manual (IOM Publication 100-04) states that
principal and other diagnosis codes are to be reported on the hospice
claims form per ICD-9-CM Coding Guidelines.
Comment: Some commenters felt that the only reason for the focus on
diagnosis is for CMS to ``save money'' while shifting costs to the
elderly and that the per diem reimbursement is being unbundled with
these coding clarifications.
Response: The goal of any clarification of longstanding, existing
policies such as those relating to ICD-9-CM Coding Guidelines is to
more fully describe Medicare beneficiaries who are receiving hospice
care. We are also accountable for maintaining the integrity and fiscal
viability of the Medicare Trust Funds. Diagnosis information on claims
is also important as we move forward with hospice payment reform.
Section 3132(a) of the Affordable Care Act for hospice payment reform
requires that payment reforms occur no earlier than October 1, 2013,
and that the revisions to the payments implemented result in the same
estimated amount of aggregate expenditures for hospice care in the
fiscal year that the revisions are implemented as would have been made
for such care in such fiscal year if such revisions had not been
implemented. That means any monies saved from any implemented reform
model must go back into the hospice benefit. The goal of hospice
payment reform is to ensure appropriate distribution of Medicare Trust
Funds by better aligning payments with resource use, to pay more
accurately.
However, there has been some concern, as noted by the Office of the
Inspector General, that some hospices are not providing the full range
of required hospice services, most notably drugs, through their per
diem reimbursement to Medicare hospice beneficiaries (OIG Report A-06-
10-00059, June, 2012). Data analysis conducted by our hospice payment
reform contractor, Abt Associates, identified that some hospice-related
drugs for Medicare hospice beneficiaries are being submitted through
Part D prescription programs instead of being covered under the
Medicare Hospice Benefit as required by the statute. In 2010, 773,168
Medicare hospice
[[Page 48246]]
beneficiaries were enrolled in Part D. Of these individuals, almost 15
percent received over 334,000 analgesic prescriptions through Part D
during hospice enrollment totaling $13,000,430. See Figure (1) below.
[GRAPHIC] [TIFF OMITTED] TR07AU13.000
This total covered only one drug class. During 2010, Medicare
hospice beneficiaries received 5,878,425 prescriptions of all classes
totaling $351,750,202. These drug classes encompassed other hospice-
related drugs including medications for nausea, shortness of breath,
anxiety, constipation, diarrhea, depression, as well as disease-
specific medications for the reported principal hospice diagnosis. We
continue to conduct ongoing analysis regarding the claims for Medicare
hospice beneficiaries to ensure that hospice providers are covering the
required services, drugs, supplies, and DME as required by our
regulations at 42 CFR 418.200, 418.202, and 418.204.
The hospice reimbursement structure has been a bundled per diem
rate since the implementation of the Medicare Hospice Benefit. It is
not our intent to ``unbundle'' any of the services required to be
provided by hospices. However, as shown in the above figure, it is
evident that many drugs used for hospice pain management are being
``unbundled'' from the hospice per diem rate, and this is a concerning
trend that we do not support.
Therefore, we continue to support the ICD-9-CM Coding Guidelines
and stand by the ICD-9-CM coding clarifications in the proposed rule.
These coding guidelines are longstanding policies that we have
reiterated in past rules and notices. No new proposals are being made;
rather we are ensuring that these existing policies are being adhered
to. As such, ``debility'' and ``adult failure to thrive'' are not
allowable as reportable principal diagnoses on the hospice claims.
However, we recognize that this may be a paradigm shift for some
hospices in the way they have coded in the past. Therefore, in
recognizing the process and systems changes that need to be put in
place, claims received with these codes in the principal diagnosis
field will be returned to the provider for more definitive coding of
the principal diagnosis and additional diagnoses, effective for claims
dated on or after October 1, 2014. This will not affect claims
submitted before October 1, 2014. ``Debility'' and ``adult failure to
thrive'' may be reported on the hospice claims as additional diagnoses
in the appropriate claim fields.
Although claims will not be returned to the provider until the
start of FY 2015, we remind hospices that they are currently, and have
always been, required to code all related diagnoses in the additional
coding fields on the hospice claim and thus should be doing so now. We
will continue to monitor and analyze hospice claims data and may make
further clarifications in the future if necessary. In addition to the
principal diagnosis field, the paper UC-04 claim form has up to 17
additional diagnosis fields and the electronic 837I 5010 claim form has
up to 24 additional diagnosis fields allowing for adequate space for
the coding all conditions related to the beneficiary's terminal
prognosis.
Comment: Many comments were also received with specific clinical
scenarios regarding beneficiaries with a reported hospice diagnosis of
``debility'' or ``adult failure to thrive.'' These comments went on to
list these beneficiaries' comorbidities including COPD, atrial
fibrillation, congestive heart failure, and stroke, to name a few.
[[Page 48247]]
Other comments included clinical presentations, rather than specific
diagnoses, and felt that ``debility'' or ``adult failure to thrive''
were the only appropriate diagnoses that could be assigned. These
commenters also report that they were unable to determine the principal
terminal diagnosis for these beneficiaries as the individual conditions
did not meet criteria for being terminally ill per LCDs. Finally,
additional commenters asked about quantifying comorbidities and whether
Medicare guidelines for eligibility would be updated to support
comorbidities as terminal diagnoses.
Response: As referenced in our regulations at Sec. 418.22(b)(1),
to be eligible for Medicare hospice services, the beneficiary's
attending physician (if any) and the hospice medical director must
certify that the individual is terminally ill, that is, the
individual's prognosis is for a life expectancy of 6 months or less if
the terminal illness runs its normal course as defined in section
1861(dd)(3)(A) of the Act and set out at in Sec. 418.22. Therefore,
eligibility under the Medicare Hospice Benefit is based on the
prognosis of the individual and not only a single diagnosis or multiple
diagnoses. As generally accepted by the medical community, the term
``terminal illness'' refers to an advanced and progressively
deteriorating illness and the illness is diagnosed as incurable. When
an individual is terminally ill, many health problems are brought on by
underlying condition(s), as bodily systems are interdependent, meaning
that there are multiple conditions, and hence diagnoses, contributing
to the terminal prognosis. In the proposed rule, we said that the ICD-
9-CM Coding Guidelines, referring to the selection of the principal
diagnosis, state to list the diagnosis which is ``chiefly responsible
for the services provided and to list additional codes that describe
any coexisting conditions.'' We clarified that the principal diagnosis
listed should be determined by the certifying hospice physician(s) as
the diagnosis most contributory to the terminal prognosis. Furthermore,
ICD-9-CM Coding Guidelines state that when there are two or more
interrelated conditions (such as diseases in the same ICD-9-CM chapter
or manifestations characteristically associated with a certain disease)
potentially meeting the definition of principal diagnosis, either
condition may be sequenced first, unless the circumstances of the
admission, the therapy provided, the Tabular List, or the Alphabetic
Index indicate otherwise. In the unusual instance when two or more
diagnoses equally meet the criteria for principal diagnosis as
determined by the circumstances of admission, diagnostic workup and/or
therapy provided, and the Alphabetic Index, Tabular List, or other
coding guidelines do not provide sequencing direction, any one of the
diagnoses may be sequenced first. The ICD-9-CM Coding Guidelines are
clear that all conditions contributing to the need for services should
be listed.
One commenter provided the following clinical scenario regarding an
individual with a hospice claims-reported principal diagnosis of
``debility:''
``A patient has dilated cardiomyopathy and arrhythmia and has a
functional classification of NYHA Class III as he has symptoms with
activity but not at rest. He also has pulmonary fibrosis causing
shortness of breath with activity. His PPS has declined to 50
percent in the last 3 months and he now needs to use a walker and
the assistance for one person ambulating <10 ft. His weight has
declined by 10 percent in the last six months, and he states that
his appetite has decreased to eating breakfast and drinking two
supplements during the day. He has been hospitalized two times in
the past year for pneumonia and was hospitalized last month for
arrhythmia requiring medication adjustments. He does not want
further hospitalizations.''
In this scenario, there are multiple conditions listed, including
dilated cardiomyopathy, arrhythmia and pulmonary fibrosis. Though any
of these conditions, individually, may not deem the individual as
terminally ill, the progressive nature of these diseases as well as the
collective presence of these multiple comorbid conditions will
contribute to the terminal prognosis of the individual. We are
clarifying that in a scenario such as this, the certifying physician
would select the condition he or she feels is most contributory to the
terminal prognosis, based on information in the comprehensive
assessment, other relevant clinical information supporting all
diagnoses, and his or her best clinical judgment. We are clarifying
that this principal diagnosis, along with the other related diagnoses,
would be included on the hospice claim. The physician's clinical
judgment does not negate the fact that there must be a basis for
hospice certification. A hospice needs to be certain that the
physician's clinical judgment can be supported by clinical information
and other documentation that provide a basis for the certification of a
life expectancy of six months or less if the illness runs its normal
course.
Additionally, the LCDs state that the terminal illness eligibility
guidelines provided therein are applicable to all hospice patients
regardless of diagnosis. The LCD guidelines are intended to be used to
identify any Medicare beneficiary whose current clinical status and
anticipated progression of disease is more likely than not to result in
a life expectancy of six months or less. LCDs are utilized to determine
eligibility for Medicare hospice services and not to determine the
appropriate diagnoses to code on hospice claims.
The eligibility requirements for Medicare hospice services were
stated above in a previous response. Eligibility under the Medicare
Hospice Benefit is based on the prognosis of the individual and these
criteria are not specific to or limited by any one condition, multiple
conditions or presence of comorbidities. Rather, the certification of
terminal illness is based in the unique clinical picture of the
individual that is reflected in the comprehensive assessment and other
clinical records and documentation that deems the person as having a
life expectancy of six months or less, should the illness run its
normal course. Therefore, the Medicare Hospice Benefit eligibility
requirements will not change as a result of the clarifications in the
proposed rule. We believe that the certifying physicians have the best
clinical experience, competence and judgment to make the determination
that an individual is terminally ill. We continue to require the
reporting of all related comorbidities, regardless of the quantity, in
the hospice clinical record and on the hospice claims.
Comment: We received several comments regarding whether the
reported principal diagnosis on the Certificate of Terminal Illness
needs to be changed for current hospice beneficiaries where
``debility'' or ``adult failure to thrive'' was reported as the
principal terminal condition.
Response: The regulations at Sec. 418.22(b) state that that the
certification include--(1) The certification must specify that the
individual's prognosis is for a life expectancy of 6 months or less if
the terminal illness runs its normal course; (2) 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 as set forth in paragraph (d)(2) of this
section. 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; (3) The physician must include a
brief narrative explanation of the clinical findings that supports a
life expectancy of 6 months or less as part of the
[[Page 48248]]
certification and recertification forms, or as an addendum to the
certification and recertification forms; (4) The physician or nurse
practitioner who performs the face-to-face encounter with the patient
described in paragraph Sec. 418.22(a)(4) must attest in writing that
he or she had a face-to-face encounter with the patient, including the
date of that visit. The attestation of the nurse practitioner or a non-
certifying hospice physician shall state that the clinical findings of
that visit were provided to the certifying physician for use in
determining continued eligibility for hospice care; and (5) All
certifications and recertifications must be signed and dated by the
physician(s), and must include the benefit period dates to which the
certification or recertification applies.
Certifications (of which the narrative is a part) are based on
prognosis, not diagnosis as described above in the Code of Federal
Regulations. Claims should include a principal diagnosis and all
related diagnoses which form the prognosis. Certifications are
completed no more than 15 days prior to the start of the benefit
period. A new certification is not required simply because a
beneficiary's principal diagnosis changes nor do benefit periods or
election status change simply because a principal diagnosis changes.
Comment: We received some comments expressing concern that no
longer allowing the use of ``debility'' and ``adult failure to thrive''
as principal hospice diagnoses would mean that Medicare hospice
beneficiaries would be forced into a Medicare ``cookie cutter'' mold
diagnosis. Several commenters stated that this would mean expensive
diagnostic testing and/or hospitalizations to determine the terminal
condition. Some commenters question what the expectations are for those
people who are just ``dying of old age'' and some asked if CMS would
rather see ``otherwise healthy but elderly patients experience multiple
hospital admissions and nursing home stays.'' Another commenter stated
that doctors may feel compelled to ``make-up'' diagnoses to satisfy
this coding clarification. One commenter asked if all codes under the
classification of ``Symptoms, Signs, and Ill-defined Conditions'' are
included in these clarifications.
Response: As stated above, these ICD-9-CM coding clarifications do
not preclude the clinical judgment of the certifying physician(s)
regarding the hospice eligibility of any given Medicare beneficiary;
rather, they are to ensure that all principal and diagnoses related to
the terminal prognosis are captured on the Medicare hospice claims to
more accurately describe hospice beneficiaries receiving the services,
drugs, supplies, and DME hospices are required to cover under the
regulations at Sec. 418.200, Sec. 418.202, and Sec. 418.204. A non-
specific, ill-defined symptom diagnosis such as ``debility'' and
``adult failure to thrive'' is more of a catch-all diagnosis in that a
wide variety of principal and/or comorbid conditions contribute to
these syndromes. Given the complexity of a hospice patient, with
multiple conditions often contributing to the terminal prognosis, we
are stating that all diagnoses contributing to (that is, related to)
the terminal prognosis of the individual are to be reported on the
hospice claims in order to account for the individual needs of each and
every Medicare hospice beneficiary.
In evaluating an individual for hospice eligibility, and especially
when evaluating an individual who has the clinical characteristics
found under ``debility'' or ``adult failure to thrive'', ``medical
history is probably more important than physical examination or
laboratory testing as failure to thrive commonly occurs over the course
of months and common diagnostic testing has generally been done
previously.\5\ '' Therefore, it is our belief that an individual who
has elected hospice care and has been determined to be terminally ill
by a certifying physician has more than likely already been assessed,
treated and evaluated by health care providers, not limited to just
hospice providers, prior to coming to the decision to elect hospice
services and waive the right to Medicare payment for other curative
services. Having all related conditions reported on the hospice claim
form, and not just a single diagnosis, such as an ill-defined, symptom
diagnosis, will ensure that hospices are aware of and provide all of
the expert care, including services, drugs, supplies, and DME, that a
Medicare hospice beneficiary requires as he or she approaches end-of-
life.
---------------------------------------------------------------------------
\5\ Verdery, R. (1997). Clinical Evaluation of Failure to Thrive
in Older People. Clinics in Geriatric Medicine. 13(4), 769-778.
---------------------------------------------------------------------------
In the rare event that no single definitive terminal diagnosis (or
diagnoses) can be determined by the certifying physician, whether from
lack of clinical documentation or patient refusal for diagnostic work-
up, then the expectation would be that all conditions that are present
at the time of hospice certification that deem the individual as
terminally ill would be reported on the hospice claim. One example
provided by a commenter is as follows:
An 85 year old patient with dysphagia, decreased oral intake,
malnutrition, weight loss, BMI of 18.6 upon admission, decreasing
functional status, progressed from a walker to chair to bed in less
than six months, but with no underlying diagnoses. This patient was
determined to be terminally ill by the certifying physician and this
patient was entered into hospice services.
In this example, while no organ-based diagnosis could be confirmed
by the certifying physician, the clinical record reflects that this
patient was suffering from malnutrition, dysphagia, and decreased
functional status and muscle weakness.
Eligibility for hospice services is not limited by only disease-
specific ICD-9-CM codes. There are ICD-9-CM codes for all of the
clinical presentations listed above. This clinical scenario has been
documented in the comprehensive assessment, and there is a clinical
history of this patient's decline. CMS's expectation is to code these
clinical presentations on the claim as they are listed in the clinical
record. The condition the physician feels is most contributory to the
terminal prognosis would be reported first on the hospice claim form,
along with all other related conditions. There appears to be some
confusion and disconnect from the comments received regarding the
coding expectations. The rationale for these clarifications is not to
limit or prohibit access to hospice services, and we expect hospice
providers to render the hospice care needed for those eligible
individuals. We are only clarifying to code this level of specificity
on the hospice claim form so we have an accurate clinical picture of
those Medicare beneficiaries that are receiving hospice care under
their Medicare Hospice Benefit. This expectation for specificity in
claims coding is found in every other health care setting for Medicare
beneficiaries--inpatient, outpatient, home health, skilled nursing
facilities, acute rehabilitation facilities and in long term care
hospitals. Hospices are expected to follow the same level of
specificity especially given the complexity of the hospice patient
population.
We recognize that this may be a great departure from the way some
hospice providers have been accustomed to coding on hospice claims.
Ongoing analysis of the hospice claims reveals that a majority of
hospices are coding a single terminal diagnosis. However, eligibility
should always have been based on the terminal prognosis of the patient,
and this prognosis would typically involve more than one diagnosis.
Specifically, as stated previously, analysis of third quarter FY
[[Page 48249]]
2013 data (April 1, 2013 through June 30, 2013 as of July 1, 2013)
showed that 69 percent of providers still only report one diagnosis on
the hospice claim. Prognosis, as many commenters have noted, is based
on a multitude of clinical processes. We expect hospices to code these
multiple clinical processes. This may be difficult for some providers
to accept as they may not understand how malnutrition, anemia, or
depression, for example, could be reported as a principal hospice
diagnosis. However, many commenters provided clinical scenarios in
which their patients had one or all of these clinical presentations
that was contributing to the terminal prognosis of the individual. We
expect hospice providers to take a holistic approach to diagnostic
coding on the claims form, reporting the principal diagnosis and all
related diagnoses.
According to Sec. 418.22(b)(3), Content of certification, ``The
physician must include a brief narrative explanation of the clinical
findings that supports a life expectancy of six months or less as part
of the certification and recertification forms; or as an addendum to
the certification and recertification forms.'' Note that ``clinical
findings'' are included in the determination of terminal prognosis, and
hospice eligibility is not limited by or to a single diagnosis or
diagnostic test result(s). Therefore, expensive diagnostic testing or
hospitalizations are not a requirement for determining whether an
individual meets Medicare hospice eligibility criteria if the
individual's clinical circumstances are evident in that the conditions
present contribute to the terminal prognosis of the individual.
Oftentimes, if an individual has reported a past, resolved problem in
their medical history, and that problem could cause the symptom
syndromes of ``debility'' or ``adult failure to thrive'', that problem
is the most likely one underlying the patient's presentation.\6\ The
expectation remains that hospice providers, using their best clinical
judgment, knowledge, and expertise, will ``paint'' a detailed picture
of their patients to more fully describe Medicare hospice patients.
---------------------------------------------------------------------------
\6\ Verdery, R. (1997). Clinical Evaluation of Failure to Thrive
in Older People. Clinics in Geriatric Medicine. 13(4), 769-778.
---------------------------------------------------------------------------
If a Medicare beneficiary is reported to be ``dying of old age'' or
``otherwise healthy, but elderly,'' we believe that characterization of
the beneficiary's condition is inconsistent with classifying the
individual as terminally ill. Eligibility criteria for the Medicare
Hospice Benefit do not include an age requirement, and advanced age
alone is inadequate documentation of terminal prognosis.
It is normal clinical practice for health care providers to fully
inform their patients about their health status. An eligible
beneficiary who is considering hospice, and who has not seen a doctor
in years, should be fully informed by the potential hospice provider
about the conditions contributing to their terminal prognosis and their
palliative treatment options for ongoing care.
Often, many other treatable health conditions could be contributing
to the clinical characteristics associated with ``debility'' and
``adult failure to thrive.'' \7\ These conditions may include:
Alzheimer's Disease, depression, primary anorexia, diabetes, cancer,
chronic lung disease, stroke, chronic urinary tract infections, chronic
steroid use, medication reactions, just to name a few. Any eligible
individual (or representative) who is electing hospice under the
Medicare Hospice Benefit must acknowledge that he or she has been given
a full understanding of the palliative rather than the curative nature
of hospice care, as it relates to the individual's terminal illness
(Sec. 418.24(b)(2)). Upon electing the Medicare hospice benefit, an
eligible patient acknowledges his/her understanding that Medicare will
no longer pay for curative treatment for the terminal illness and
related conditions, and thus the patient is essentially waiving
curative treatment under Medicare, and instead elects to receive
palliative care to manage pain or symptoms. It is the hospice
provider's responsibility to ensure that the individual is fully
informed and acknowledges understanding that he or she is essentially
waiving curative treatment and electing only palliative care, so the
individual (or representative) can make his or her own informed
decision.
---------------------------------------------------------------------------
\7\ Verdery, R. (1997). Clinical Evaluation of Failure to Thrive
in Older People. Clinics in Geriatric Medicine. 13 (4), 769-778.
---------------------------------------------------------------------------
The expectation remains that all conditions (hence, diagnoses) that
are contributing to (that is, related to) the terminal prognosis of the
individual would be reported on the hospice claims to fully represent
the individual's clinical status and the hospice interventions that are
being provided to address the individual's needs.
We do not endorse ``making up'' a diagnosis in order for hospice
claims submission. We believe that beneficiaries' physicians are in the
best clinical position to determine those conditions that are
contributing to the terminal prognosis of their patients. We expect
that they will use responsible decision making to determine the
diagnosis contributing most to the terminal prognosis utilizing the
information from the clinical records and the comprehensive
assessments. While the ICD-9-CM Coding Guidelines for ``Symptoms, Signs
and Ill-defined Conditions'' do apply for all codes under this ICD-9-CM
classification, we are currently focusing on the two most frequently
reported hospice claims diagnoses from this classification,
``debility'' and ``adult failure to thrive.'' However, we will continue
to monitor the diagnostic coding patterns on hospice claims for any
further issues or clarifications that may be needed in this regard.
Comment: A few commenters suggested, for those cases reported with
``debility'' or ``adult failure to thrive'' as the principal diagnosis,
there should be a mandatory medical review rather than these patients
not receiving hospice care or to only ``punish'' those that have abused
``debility.'' One commenter suggested that CMS limit the number of
patients per hospice with ``debility'' and ``adult failure to thrive''
with a 3 percent cap.
Response: As noted previously, ``debility'' and ``failure to
thrive'' comprised 20 percent of the Medicare hospice population in FY
2012. This is a substantial number of individuals that hospice
providers are saying have no other diagnoses or conditions that could
be determined or confirmed. Conducting mandatory medical reviews on
each and every one of these cases would require substantial
administrative burden and costs. Rather, we are not stating that
individuals with the clinical manifestations of ``debility'' and
``adult failure to thrive'' are ineligible for hospice services under
the Medicare Hospice Benefit. Eligibility is determined by the
certifying physician and based on the review of the clinical records
and comprehensive assessment. These clarifications are to ensure that
hospice providers are fully describing their Medicare hospice patients,
which should assist them in fully understanding and treating all of the
conditions contributing to the terminal prognosis and not just a single
terminal diagnosis.
It is our belief that hospice providers would not support having
another cap requirement regarding their census populations. We
recognize there are many new and ongoing requirements that hospice
providers must fulfill in addition to providing high-quality, end-of-
life care for Medicare beneficiaries.
[[Page 48250]]
Therefore, it is not our intent, at this time, to implement any new cap
requirements or ``punishments'' on hospice providers with these coding
clarifications. We expect that hospice providers will continue to
assess and evaluate their own organizational policies and processes to
ensure that they are able to meet requirements and to continue to meet
the needs of their patients.
Comment: One commenter stated, ``The need to document secondary
diagnoses is recognized. It was actually commonly done in the pre-
electronic record (EMR) days, but got lost by many hospices with
limitations in software systems''. One commenter stated that barriers
existed with electronic medical record systems that did not allow
additional diagnoses to flow to the claim. These commenters went on to
say that many of these barriers have been removed and that the majority
of hospice providers are either now in compliance with the requirement
to include multiple diagnoses or are in the process of implementing
procedures and technology in order to be in compliance. One commenter
stated that their hospice software vendor has not developed a process
to allow for inclusion of related diagnoses on their claims forms. This
commenter went on further to say that it would be an obstacle for
hospice providers to make software changes to comply with the ICD-9-CM
coding clarifications regarding the reporting of related diagnoses.
Several commenters stated that the occurrence of reporting a principal
diagnosis of ``debility'' or ``adult failure to thrive'' is uncommon.
Response: We appreciate the comment regarding the common hospice
practice of including secondary diagnoses in the past. While we
understand that software systems may pose some obstacles in reporting
more than one diagnosis on the hospice claim, we also believe that this
practice of reporting the conditions contributing to (that is, related
to) the terminal prognosis is one that has been communicated since the
implementation of the hospice benefit. The expectation is for this
practice to continue and for hospice providers to be active in ensuring
that their processes and systems promote the hospice philosophy of
holistic, comprehensive care and the intent of the Medicare Hospice
Benefit in supporting that access for the Medicare population.
As mentioned in the proposed rule, there are hospice providers who
are reporting more than just the principal diagnosis, so it appears
that there are electronic systems currently in place that allow for the
inclusion of multiple diagnoses. However, data analysis of hospice
claims continues to show that the majority of hospice providers (69
percent of hospice providers, as stated in previous responses) continue
to report only one diagnosis on hospice claims. Additionally, software
systems are typically designed with end user input so we believe those
software systems that only allow one diagnosis were because those
hospices communicated to the software vendors that their needs for
claims coding were to include only one diagnosis. We expect hospices to
articulate to the vendors the requirements of the software that
complies with our requirements. Furthermore, we have reiterated in past
notices and rules regarding our expectation of the inclusion of the
principal hospice diagnosis as well as all related conditions. As
mentioned previously, in addition to the principal diagnosis field, the
paper UC-04 claim form has up to 17 additional diagnosis fields, and
the electronic 837I 5010 claim form has up to 24 additional diagnosis
fields allowing for adequate space for the coding all conditions
contributing to (that is, related to) the beneficiary's terminal
condition. Therefore, we believe that we have provided ample notice and
time for hospice providers to evaluate their claims software systems to
make the necessary systems adjustments for the inclusion of all related
diagnoses. However, we also recognize that this will require some
software systems adjustments for several hospice providers, and we are
sensitive to those time requirement needs. To address the comments
regarding the rare occurrences of the use of ``debility'' or ``adult
failure to thrive'' as a principal diagnosis, a review of 2011 and 2012
data from the Chronic Condition Warehouse revealed the following
information (See Table 4 and Table 5):
Table 4--Percentage of Hospice Providers Ever Reporting ``Debility'' or
``Adult Failure To Thrive'' as the Principal Hospice Diagnosis With No
Reported Secondary Diagnoses
------------------------------------------------------------------------
Condition FY 2011 % FY 2012 %
------------------------------------------------------------------------
Debility.......................................... 89.3 88.9
Adult Failure to Thrive........................... 87.3 87.6
------------------------------------------------------------------------
Source: FY 2011 and FY 2012 Claims from Chronic Conditions Warehouse
(CCW). Accessed on 7/19/13.
Table 5--Percentage of Claims With ``Debility'' or ``Adult Failure To
Thrive'' as Reported Principal Diagnosis With No Reported Secondary
Diagnoses
------------------------------------------------------------------------
FY 2011 FY 2012
Condition (%) (%)
------------------------------------------------------------------------
Debility.......................................... 11.96 12.07
Adult Failure to Thrive........................... 7.55 7.83
------------------------------------------------------------------------
Source: FY 2011 and FY 2012 Claims data from Chronic Conditions
Warehouse (CCW). Accessed on 7/19/13.
This data indicates that the majority of hospice providers are
reporting ``debility'' and ``adult failure to thrive'' as a principal
hospice diagnosis, thus this is not a rare occurrence as commenters
have stated. Additionally, claims with ``debility'' or ``adult failure
to thrive'' as the reported principal hospice diagnosis accounted for
almost 20 percent of total hospice claims for both FY 2011 and FY 2012.
Comment: We received several comments regarding hospice claims with
a principal diagnosis of ``debility'' or ``adult failure to thrive''
being returned to the provider immediately for more definitive coding.
Some expressed that CMS is ``jumping the gun'' by announcing that
claims would be returned to the provider before the comment period is
over and were concerned that claims would starting returning upon
publication of the proposed rule. Several commenters expressed concern
regarding the ``denial of claims payment'' for claims received with
``debility'' or ``adult failure to thrive'' reported as the principal
diagnosis.
Response: We apologize for any confusion that may have resulted
from our statement in the FY 2014 Hospice Wage Index and Payment Rate
Update proposed rule regarding claims being returned to providers for
more definitive coding. We stated in the proposed rule: ``. . . we
would clarify that ``debility'' and ``adult failure to thrive'' would
not be used as principal diagnoses of the hospice claim form. When
reported as a principal diagnosis, these would be considered
questionable encounters for hospice care, and the claims would be
returned to the provider, not denied, for a more definitive principal
diagnosis.'' We did not specify any time frame for these claims or the
effective date of implementation. The intent was not to immediately
return claims to the provider upon publication of the proposed rule,
and the returned claim is not a denial of the claim, but a request for
a more definitive and appropriate
[[Page 48251]]
principal diagnosis. ``Debility'' and ``adult failure to thrive'' could
be reported on the hospice claim as other, additional, or coexisting
diagnoses. We understand that this is a shift from the way some hospice
providers have coded in the past and that there needs to be adequate
time to ensure that all clinical and electronic processes are in place
and functioning as not to create unnecessary administrative burden in
an accelerated time frame.
Comment: There were several comments questioning what is considered
related or unrelated to the terminal condition. One commenter stated
that it is difficult to determine if a diagnosis is related to the
terminal condition with an example given stating that renal failure may
or may not be related to congestive heart failure. Another commenter, a
hospice physician, provided a clinical scenario for a beneficiary with
chronic obstructive pulmonary disease (COPD) as the principal
diagnosis, but who also had coronary artery disease (CAD) and
Parkinson's disease which the hospice considered unrelated comorbid
conditions. The patient would only receive hospice services for care
related to the lung disease (COPD). Another commenter expressed concern
that including all of the related diagnoses on the hospice claim would
mean that hospices would have additional costs incurred in covering all
of the medications for the reported diagnoses.
Response: It is our goal to maintain the integrity of hospice
philosophy and the Medicare Hospice Benefit. The intent of the Medicare
Hospice Benefit is to provide all-inclusive care for pain relief and
symptom management for the terminal prognosis and related conditions,
and offer the opportunity to die with dignity in the comfort of one's
home rather than in an institutional setting. It is often not a single
diagnosis that represents the terminal prognosis of the patient, but
the combined effect of several conditions that makes the patient's
prognosis terminal. In Sec. 418.54(c), the hospice Conditions of
Participation stipulate that the comprehensive hospice assessment must
identify the patient's physical, psychosocial, emotional, and spiritual
needs related to the terminal illness and related conditions which must
be addressed in order to promote the hospice patient's well-being,
comfort, and dignity throughout the dying process. The comprehensive
assessment must take into consideration the following factors: The
nature and condition causing admission (including the presence or lack
of objective data and subjective complaints); complications and risk
factors that affect care planning; functional status; imminence of
death; and severity of symptoms (Sec. 418.54(c)). The Medicare Hospice
Benefit requires the hospice to cover all palliative care related to
the terminal illness and related conditions. The hospice plan of care
is established based on the review of the clinical records and the
comprehensive hospice assessments in order to ensure that all care
needs at the end-of-life are addressed. Section 1861(dd)(1) of the Act
establishes the services that are to be rendered by a Medicare
certified hospice program. These covered services include: Nursing
care; physical therapy; occupational therapy; speech-language pathology
therapy; medical social services; home health aide services (now called
hospice aide services); physician services; homemaker services; medical
supplies (including drugs and biologics); medical appliances;
counseling services (including dietary counseling); short-term
inpatient care (including both respite care and procedures necessary
for pain control and acute or chronic symptom management) in a
hospital, nursing facility, or hospice inpatient facility; continuous
home care during periods of crisis and only as necessary to maintain
the terminally ill individual at home; and any other item or service
which is specified in the plan of care and for which payment may
otherwise be made under Medicare, in accordance with Title XVIII of the
Act.
We recognize that there are conditions that are unrelated to the
terminal condition of the individual. This is why there are the ongoing
assessment requirements of the hospice beneficiaries and the
collaboration with the hospice IDG--to ensure that the ongoing and
changing needs of the hospice beneficiary are assessed and changes to
the plan of care are made. However, in referring to the holistic intent
of hospice philosophy and care, we wrote in the August 22, 1983
proposed rule, ``. . . we recognize that there are many illnesses which
may occur when an individual is terminally ill which are brought on by
the underlying condition of the patient'' (48 FR 38147). In reviewing
the many clinical scenarios provided by commenters and their
interpretations of what they consider related versus unrelated, it is
apparent that the majority refer to a ``related condition'' as one that
is related only to the reported single, principal terminal diagnosis
and not to the terminal prognosis. However, within those same comments,
it was stated numerous times that hospice eligibility is related to the
prognosis of the individual. One example provided from a hospice
physician regarding a Medicare hospice beneficiary who had a reported
principal terminal diagnosis of chronic obstructive pulmonary disease
(COPD). This individual also had documented coronary artery disease
(CAD) and Parkinson's disease. The provider stated that the CAD and the
Parkinson's disease are unrelated to the COPD and that the patient
would only receive hospice services for the COPD. This scenario and
accompanying statement does not appear to encompass hospice philosophy
of holistic care. Therefore, we are restating what we communicated in
the December 16, 1983 Hospice final rule regarding what is related
versus unrelated to the terminal illness: ``. . . [W]e believe that the
unique physical condition of each terminally ill individual makes it
necessary for these decisions to be made on a case-by-case basis. As
stated in the December 16, 1983 Hospice final rule, . . . ``hospices
are required to provide virtually all the care that is needed by
terminally ill patients.'' (48 FR 56010). Therefore, unless there is
clear evidence that a condition is unrelated to the terminal prognosis,
all services would be considered related. It is also the responsibility
of the hospice physician to document why a patient's medical need(s)
would be unrelated to the terminal prognosis. We continue to reiterate
that this determination of what is related versus unrelated to the
terminal prognosis remains within the clinical expertise and judgment
of the hospice medical director in collaboration with the IDG.
Comment: Two commenters stated that the reference to the 1983 final
rule preamble language quoted above, is casting aside language found in
the Sec. 418.402, ``Individual liability for services that are not
covered hospice care''. These comments went on to say that Sec.
418.402 ``identified items as unrelated and not the responsibility of
the hospice for `services received for the treatment of an illness or
injury not related to the individual's terminal condition'.''
Response: The referenced Sec. 418.402, ``Individual liability for
services that are not considered hospice care'' states, ``Medicare
payment to the hospice discharges an individual's liability for payment
for all services, other than the hospice coinsurance amounts described
in Sec. 418.400. . .'' This section goes on to state what payment
liabilities a hospice beneficiary would be responsible for (not the
hospice provider per the commenters) including ``. . . Medicare
deductibles and
[[Page 48252]]
coinsurance payments and for the difference between the reasonable and
actual charge on unassigned claims on other covered services that are
not considered hospice care.'' Examples of non-hospice services are
provided in this section including ``. . . Medicare services received
for the treatment of an illness or injury not related to the
individual's terminal condition.'' We have previously acknowledged that
there are those rare circumstances in which a service may not be
related to the patient's terminal prognosis and that this determination
is to be done on a case-by-case basis by the hospice physician with
input from the IDG. However, Sec. 418.402 refers to the liability
limitations for the hospice beneficiary and does not refer to the
liability to the hospice provider. To infer that this section is a
confirmation of the liability limitations to the hospice provider would
be incorrect.
Comment: Several commenters stated that the hospice physician,
along with input from the IDG, have a process in place to help
determine related versus unrelated conditions and results in the
holistic and comprehensive care their patients need. Other commenters
explained that the software system utilized by their hospice agency
marks conditions either as ``active'' (meaning, related) or
``historical'' (meaning, unrelated). If a condition went from a
historical state to an active state during the course of a hospice
episode, then that condition was then considered related and treated
accordingly under the hospice plan of care. Another commenter said that
while some conditions are unrelated to the terminal condition, the
clinical manifestations of these unrelated conditions are as such that
they contribute to the individual's symptom burden, and the hospice
provider still provides symptom management for these seemingly
unrelated conditions to meet the patient's needs.
Response: We applaud these hospices in providing a patient-centered
approach and embracing the holistic hospice philosophy. These are all
examples of hospice providers coming up with innovative ways to manage
the needs of the hospice beneficiaries. These are reflections of the
true intent of hospice philosophy that have been incorporated into the
Medicare Hospice Benefit. We encourage all hospice providers to assess
their operational processes and clinical and claims systems to be
innovative in meeting the challenges of providing end-of-life care for
the Medicare hospice beneficiaries as health care, in general,
transitions to accountability and value-based models of care.
Comment: One commenter stated that these diagnostic clarifications
are a change in coverage policy and CMS must use a National Coverage
Decision process to change coverage policy rather than through the
preamble discussion of the proposed rule.
Response: We continue to state that these coding clarifications are
for hospice claims reporting only and are not a question of hospice
eligibility or access to coverage. Eligibility to access the Medicare
Hospice Benefit remains the same since the implementation of the
benefit in 1983. To restate, eligibility for the Medicare Hospice
Benefit is based on the individual being entitled to Part A of Medicare
and being certified as terminally ill in accordance with Sec. 418.22.
These eligibility requirements for coverage have not changed and are
not changing in this rule. We expect hospice providers will not
discharge, from hospice services, those beneficiaries who meet
eligibility requirements but for whom they cannot determine a single,
principal hospice diagnosis. If a Medicare beneficiary meets the
eligibility requirements as stated in Sec. 418.20 and as referenced
above, that Medicare beneficiary will have access to hospice services
under the Medicare Hospice Benefit. The intent of these coding
clarifications is to request more clarity and detail on the hospice
claims to reflect a complete picture of the Medicare hospice population
and the hospice services rendered and not to make any changes in
coverage or eligibility policies. Therefore, we reject the comment that
CMS must use the National Coverage Decision process.
Comment: We received a few suggestions to help further
clarification regarding diagnostic coding in the hospice setting. One
commenter suggested that CMS work with the National Hospice and
Palliative Care Organization (NHPCO) to develop guidelines regarding
diagnostic coding for hospices. Another commenter suggested that CMS
needs to guide standardization of the hospice industry. The American
Academy of Hospice and Palliative Medicine (AAHPM) suggested
collaboration with CMS to convene a Palliative Medicine and Hospice
Coding and Documentation Learning Network to have ongoing dialogue
regarding coding issues and suggestions for the hospice industry.
Response: We appreciate the numerous thoughtful and insightful
suggestions that have been provided in response to the diagnostic
clarifications. CMS strives to involve all stakeholders in the
collaborative process as health care navigates through the 21st century
and health care reform provisions. We continue to have ongoing
discussions with the industry, including the national hospice
organizations, to remain aware of the issues that affect the hospice
providers and impact Medicare beneficiaries. We believe that this
communication and collaboration will reflect in our ongoing advocacy
for the Medicare hospice beneficiaries to ensure accountability,
responsibility and quality end-of-life care. We will continue to
provide outcomes of these communications via Medicare Learning Network
(MLN) articles and through our Open Door Forums to ensure that all
Medicare stakeholders are kept informed of progress in maintaining the
integrity of the Medicare Hospice Benefit.
Final Decision: We will require these coding changes beginning on
October 1, 2014. On or after October 1, 2014, any claims with
``debility'' or ``adult failure to thrive'' in the principal diagnosis
field will be returned to the provider for more definitive principal
diagnosis coding. Claims submitted prior to October 1, 2014 with
``debility'' or ``adult failure to thrive'' in the principle diagnosis
field on the claim will not be returned to the provider, but we expect
that hospice providers will code the principal hospice diagnosis
according to the ICD-9-CM Coding Guidelines and the clarifications made
herein. This should provide more than ample time for hospice providers
to meet with clinical staff and their software vendors to ensure that
these coding needs are addressed and processes put into place to ensure
continuity of care and systems. These returned claims, based on the
principal diagnoses of ``debility'' or ``adult failure to thrive,'' are
not a denial of payment because of questionable eligibility; rather,
these claims are being returned for additional clarity. Once
resubmitted with diagnostic codes following the ICD-10-CM Coding
Guidelines, these claims will be processed and paid accordingly.
However, we expect hospice providers to transition immediately to more
thoughtful coding practices in advance of this effective date.
3. Use of ``Mental, Behavioral and Neurodevelopmental Disorders'' ICD-
9-CM Codes
In the proposed rule we discussed the use of hospice claims-
reported principal hospice diagnoses that fall under the ICD-9-CM
classification, ``Mental, Behavioral and Neurodevelopmental
Disorders.'' There are several codes that fall under this
classification that
[[Page 48253]]
encompass multiple dementia diagnoses that are frequently reported
principal hospice diagnoses on hospice claims, but are not appropriate
principal diagnoses per ICD-9-CM Coding Guidelines. There are, however,
other ICD-9-CM dementia codes, such as those for Alzheimer's disease
and others, that fall under the ICD-9-CM classification, ``Diseases of
the Nervous System and Sense Organs'' which are acceptable as principal
diagnoses per ICD-9-CM coding guidelines.
Comment: One commenter expressed concern that ``Lewy Body
Dementia,'' ``Fronto-temporal Dementia'' and ``Vascular Dementia'' are
no longer allowed as principal hospice diagnoses. Another commenter
questioned what would be the recommendation if the hospice provider is
unable to determine the cause of the dementia either from a lack of
medical records or specific diagnostic work-up. One commenter asked if
the LCD for ``Alzheimer's Disease and Related Disorders'' would be
applicable to use for coding guidance.
Response: In the FY 2014 Hospice wage index and payment rate update
proposed rule (78 FR 27823), we did not state the specific dementia
conditions and their corresponding ICD-9-CM codes that fall under
various coding and sequencing conventions in the ICD-9-CM Coding
Guidelines. There are many codes for dementia conditions, including the
neurological causes as well as the clinical mental and behavioral
manifestations of the underlying condition. These dementia conditions
and ICD-9-CM codes are too numerous to list within the context of the
proposed and final rules but are found in the ICD-9-CM Official
Guidelines for Coding and Reporting manual. However, we clarified that
dementia codes can be found under two classifications in the ICD-9-CM
Official Guidelines for Coding and Reporting, ``Mental, Behavioral and
Neurodevelopmental Disorders'' and ``Diseases of the Nervous System and
Sense Organs.'' Per ICD-9-CM Coding Guidelines, several, but not all,
of these ICD-9-CM dementia codes are considered manifestation codes,
especially those dementia codes classified under ``Mental, Behavioral
and Neurodevelopmental Disorders''. In accordance with the 2012 ICD-9-
CM Coding Guidelines, ``certain conditions have both an underlying
etiology and multiple body system manifestations due to the underlying
etiology. For such conditions, the ICD-9-CM has a coding convention
that requires the underlying condition be sequenced first followed by
the manifestation. Wherever such a combination exists, there is a ``use
additional code'' note at the etiology code, and a ``code first'' note
at the manifestation code. These instructional notes indicate the
proper sequencing order of the codes, etiology followed by
manifestation.'' In most cases, these manifestation codes will have in
the code title, ``in diseases classified elsewhere'' or ``in conditions
classified elsewhere.'' Codes with this in the title are a component of
the etiology/manifestation convention. The codes with the phrase ``in
diseases classified elsewhere'' or ``in conditions classified
elsewhere'' in the title indicate that they are manifestation codes.
``In diseases classified elsewhere'' or ``in conditions classified
elsewhere'' codes are never permitted to be used as first listed or
principal diagnosis codes and they must be listed following the
underlying condition. However, there are manifestation codes that do
not have ``in diseases classified elsewhere'' or ``in conditions
classified elsewhere'' in their title. For such codes a ``use
additional code'' note would still be present, and the rules for coding
sequencing still apply. We noted that several dementia codes which are
not allowable as principal diagnoses per ICD-9-CM coding guidelines are
under the classification of ``Mental, Behavioral and Neurodevelopmental
Disorders.'' According to the ICD-9-CM Coding Guidelines for ``Mental,
Behavioral and Neurodevelopmental Disorders'', dementias that fall
under this category are ``most commonly a secondary manifestation of an
underlying causal condition.''
Two of the most frequently reported dementia codes on hospice
claims fall under this manifestation/etiology convention: ``dementia in
conditions classified elsewhere with behavioral disturbance'' and
``dementia in conditions classified elsewhere without behavioral
disturbance''. Per ICD-9-CM Coding Guidelines, these codes are not
acceptable as a reported principal diagnosis, and the underlying
physical condition must be coded first. These codes can be used as
additional or other diagnoses on the hospice claim. Additionally, two
other frequently reported dementia codes on hospice claims have
underlying disease-specific sequencing conventions: ``senile dementia,
uncomplicated'' and ``other persistent mental disorders due to
conditions classified elsewhere''. There are ICD-9-CM Coding Guidelines
specific to each of these codes and these codes cannot be used as the
principal diagnosis but can be reported as additional or other
diagnoses on the hospice claim. Instructional notes regarding the
sequencing convention for each of these codes can be found under each
of these codes in the Tabular List within the ICD-9-CM Official
Guidelines for Coding and Reporting. Therefore, it is imperative that
hospice providers understand and follow ICD-9-CM Coding Guidelines and
sequencing rules for all diagnoses and especially those noted above. We
encourage hospice providers to pay particular attention to dementia
coding as there are dementia codes found in more than one ICD-9-CM
classification chapter, and there are multiple coding guidelines
associated with these dementia conditions.
The clarification of these coding guidelines is not to determine
eligibility for hospice services, but rather, these guidelines are to
assist with the proper coding sequences for the hospice claims.
Eligibility for Medicare hospice services continues to be based on the
prognosis of the individual based on the clinical judgment of the
certifying physician that the individual has a life expectancy of 6
months or less if the terminal condition runs its normal course. CMS
does not make any recommendations as to what specific diagnoses to
select from the ICD-9-CM Official Guidelines for Coding and Reporting
for an individual beneficiary as these selections are to be determined
by the certifying physician(s) based on the clinical record review and
the comprehensive assessment. There are dementia diagnoses, including
Alzheimer's Disease, Lewy-Body Dementia, fronto-temporal dementia, and
senile degeneration of the brain, to name a few, that are allowable as
principal diagnoses per ICD-9-CM Coding Guidelines and are located
under the classification of ``Diseases of the Nervous System and Sense
Organs'' in the ICD-9-CM Official Guidelines for Coding and Reporting
manual.
Some of the ICD-9-CM dementia diagnoses take into account that some
dementia conditions may be unspecified in the event that a definitive
diagnostic work-up was not or could not be performed. However, based on
the present and historical clinical presentation of the individual,
there are unspecified dementia diagnoses and corresponding ICD-9-CM
codes that are acceptable as a principal diagnosis per ICD-9-CM Coding
Guidelines. Most of these codes can be found under the classification,
``Diseases of the Nervous System and Sense Organs.'' However, the
expectation remains that the certifying physician will select the
appropriate diagnoses and codes that determine the terminal prognosis
of the
[[Page 48254]]
individual and that are most contributory to the terminal decline.
4. Guidance on Coding of Principal and Other, Additional, and/or Co-
existing Diagnoses
In the FY 2014 Hospice Wage Index and Payment Rate Update proposed
rule, we stated based on the ICD-9-CM Coding Guidelines, that the
circumstances of an inpatient admission always govern the selection of
principal diagnosis (78 FR 27833). The principal diagnosis is defined
in the Uniform Hospital Discharge Data Set (UHDDS) as ``that condition
established after study to be chiefly responsible for occasioning the
admission of the patient to the hospital for care.'' In analyzing
frequently reported principal hospice diagnoses, data analysis revealed
differences between reported principal hospice diagnoses and reported
principal hospital diagnoses in patients who elected hospice within 3
days of discharge from the hospital. In addition, in the proposed rule
we stated that our expectation is for hospice providers to report all
coexisting or additional diagnosis related to the terminal prognosis
and related conditions.
Comment: Several commenters said that these statements could be
interpreted to mean that the principal hospice diagnosis must always
mirror the hospital diagnosis and while this is often the case, there
are sometimes specific clinical scenarios in which this would not
necessarily occur. The commenters requested further clarification so
that hospice providers do not feel compelled to violate their own
coding judgment just to replicate the inpatient hospital diagnoses
based on ``mandates'' from CMS.
Response: In our statements regarding the guidelines governing the
selection of the principal hospice diagnosis, they were made to provide
additional guidance on the selection of the principal diagnosis for
hospice providers based on the ICD-9-CM Coding Guidelines. We recognize
that the principal hospice diagnosis may not mirror the inpatient
hospital diagnosis in certain circumstances. The scenario below,
provided by a commenter, is an example:
A patient was admitted to the hospital with a diagnosis of
pneumonia. Upon diagnostic work-up, it was discovered that the
patient had stage 4 lung cancer. The patient opted not to pursue
curative treatment and was discharged to home with hospice services
in place. The principal hospice diagnosis selected for this patient
was lung cancer.
This would be an appropriate principal hospice diagnosis, though it was
not the same as the primary hospital diagnosis. However, in the FY 2014
hospice wage index and payment rate update proposed rule, we presented
data analysis where the principal hospital diagnosis was a cancer
diagnosis, but the hospice diagnosis was not. It would be expected
that, in a cancer diagnosis, in which the individual received inpatient
medical care for that diagnosis and was discharged home with hospice
election within three days, that the principal hospice diagnosis would
be the inpatient hospital diagnosis of cancer. However, to clarify, we
are not requiring that the principal hospice diagnosis always must be
the exactly the same as the inpatient hospital diagnosis. We continue
to reiterate that the certifying physician, using his or her expert
clinical judgment and supporting documentation from the clinical
records and the comprehensive assessment(s), will determine the most
appropriate principal diagnosis, along with other, additional related
diagnoses, that are contributing to the terminal prognosis of the
individual. Our purpose in providing these statements in the proposed
rule was to remind providers of the ICD-9-CM Coding Guidelines which
state, to list first the diagnosis shown in the medical record to be
chiefly responsible for the services provided and to list additional
codes that describe any coexisting conditions.
Comment: One commenter questioned what the expectation is for the
number of other, additional diagnoses that should be reported on the
hospice claim. This commenter stated that it was not the hospice's
standard to report diagnoses not related to the terminal prognosis on
the hospice claim. Another commenter stated that hospice providers
historically were ``cautioned for potential enticement by covering too
many diagnoses.'' A few commenters expressed concern about how CMS may
use additional information of the secondary and tertiary diagnoses for
complex patients.
Response: We do not require hospice's to report a specific number
of diagnoses on the hospice claims. However, ICD-9-CM Coding Guidelines
are specific in its instructions to providers to ``code all documented
conditions at the time of the encounter/visit, and require or affect
patient care treatment or management.'' Therefore, we expect that
hospice providers will adhere to these guidelines in reporting the
appropriate diagnoses to more fully describe the Medicare hospice
beneficiaries receiving care and services needed to palliate and manage
their terminal conditions, based on the information from the
comprehensive assessment and individualized hospice plan of care. Our
regulations at Sec. 418.200, hospices must provide all services
reasonable and necessary for the palliation and management of the
terminal illness and related conditions. As noted, we require hospices
to provide virtually all the care that is needed by terminally ill
patients. Therefore, unless there is clear evidence that a condition is
unrelated to the terminal prognosis, all services would be considered
related. It is also the responsibility of the hospice physician to
document why a patient's medical need(s) would be unrelated to the
terminal prognosis. We expect that hospice providers will use their
best clinical judgment in determining which diagnoses and conditions
are related to the terminal prognosis of the individual receiving
hospice care and will report those diagnoses and conditions accordingly
on the hospice claims.
In response to the comment regarding the diagnosis not being
available at the time of referral, we understand that a diagnosis may
not be provided at the time of hospice referral given the sometimes
acute nature of a hospice referral. However, upon the hospice
physician's review of the comprehensive assessment along with the other
clinical records, the expectation is that a diagnosis for hospice
claims coding should be determined based on this review along with the
hospice physician's best clinical judgment as to the condition most
contributory to the terminal prognosis.
Furthermore, the expectation is to provide the diagnostic codes on
the claim to reflect the individual's clinical status regardless of the
number of diagnoses to do so. There are an ample number of diagnosis
fields on the hospice claims for reporting. Because the hospice
reimbursement is a bundled per diem rate, there is no enticement for
reporting too many. The goal of requesting all of the related diagnoses
on the hospice claim is to have a more accurate picture of the Medicare
hospice beneficiary population. This accurate picture of the Medicare
hospice population will also help to ensure that any payment reform
model that is considered is done so in a responsible and thoughtful
manner to protect the viability, integrity, and intent of the Medicare
Hospice Benefit and the care philosophy of the hospice industry.
5. Transition to ICD-10-CM
In the FY 2014 Hospice Wage Index and Payment Rate Update proposed
rule we reminded hospice providers of the upcoming transition from ICD-
9-CM to ICD-10-CM on October 1, 2014. We
[[Page 48255]]
provided additional information regarding the transition to ICD-10-CM
that is available through the CMS Web site at: https://www.cms.gov/Medicare/Coding/ICD10/?redirect=/icd10; and ICD-10-CM coding
guidelines can be found on the CDC's Web site at www.cdc.gov/nchs/data/icd10/10cmguidelines2012.pdf.
Comment: We received multiple comments asking to suspend the
enforcement of the clarifications of ICD-9-CM Coding Guidelines until
the implementation of ICD-10-CM. It was stated that the preparation for
the transition to ICD-10-CM was burdensome enough for hospice
providers.
Response: The transition to ICD-10-CM has been discussed in
previous hospice rules and notices, and the transition deadline for
ICD-10-CM has already been pushed back until its current October 1,
2014 implementation date to allow for providers to have adequate time
to prepare their administrative processes and systems. Additionally, in
our regulations at 45 CFR 162.1002, the Secretary adopted the ICD-9-CM
code set, including The Official ICD-9-CM Guidelines for Coding and
Reporting. The CMS' Hospice Claims Processing manual (Pub 100-04,
chapter 11) requires that hospice claims include other diagnoses ``as
required by ICD-9-CM Coding Guidelines''. Furthermore, these ICD-9-CM
Coding Guidelines have been existing and longstanding policies that
should be adhered to by all providers.
Other health care providers in both the inpatient and outpatient
settings are required to follow these coding guidelines, and
enforcement of these policies has been part of their payment systems
for years. The expectation for hospice providers to follow those same
guidelines is imperative to ensure continuity and quality of care
throughout a Medicare beneficiary's health care continuum. Therefore,
we stand by our clarifications regarding the ICD-9-CM Coding Guidelines
and ICD-10-CM Coding Guidelines. However, in response to the comments
received regarding the additional time needed to implement these coding
clarification changes within their software systems, we will require
these coding changes beginning on October 1, 2014, when all hospice
claims submitted on or after October 1, 2014 will be subject to having
claims returned if presented for payment with incorrect codes.
B. The Hospice Quality Reporting Program
1. Background and Statutory Authority
Section 3004 of the Affordable Care Act amended the Act to
authorize a quality reporting program for hospices. Section
1814(i)(5)(A)(i) of the Act requires that beginning with FY 2014 and
each subsequent FY, the Secretary shall reduce the market basket update
by 2 percentage points for any hospice that does not comply with the
quality data submission requirements with respect to that FY. Depending
on the amount of the annual update for a particular year, a reduction
of 2 percentage points could result in the annual market basket update
being less than 0.0 percent for a FY and may result in payment rates
that are less than payment rates for the preceding FY. Any reduction
based on failure to comply with the reporting requirements, as required
by section 1814(i)(5)(B) of the Act, would apply only for the
particular FY involved. Any such reduction will not be cumulative and
will not be taken into account in computing the payment amount for
subsequent FYs.
Section 1814(i)(5)(C) of the Act requires that each hospice submit
data to the Secretary on quality measures specified by the Secretary.
The data must be submitted in a form, manner, and at a time specified
by the Secretary. Any measures selected by the Secretary must have been
endorsed by the consensus-based entity which holds a contract regarding
performance measurement with the Secretary under section 1890(a) of the
Act. This contract is currently held by the NQF. However, section
1814(i)(5)(D)(ii) of the Act provides that in the case of a specified
area or medical topic determined appropriate by the Secretary for which
a feasible and practical measure has not been endorsed by the
consensus-based entity, the Secretary may specify measures that are not
so endorsed as long as due consideration is given to measures that have
been endorsed or adopted by a consensus-based organization identified
by the Secretary. Section 1814(i)(5)(D)(iii) of the Act requires that
the Secretary publish selected measures applicable with respect to FY
2014 no later than October 1, 2012.
2. Quality Measures for Hospice Quality Reporting Program and Data
Submission Requirements for Payment Year FY 2014
The successful development of a Hospice Quality Reporting Program
(HQRP) that promotes the delivery of high quality healthcare services
is our paramount concern. We seek to adopt measures for the HQRP that
promote efficient and safer care. Our measure selection activities for
the HQRP takes into consideration input we receive from the Measure
Applications Partnership (MAP), convened by the National Quality Forum
(NQF), as part of a pre-rulemaking process that we have established and
are required to follow under section 1890A of the Act. The MAP is a
public-private partnership comprised of multi-stakeholder groups
convened by the NQF for the primary purpose of providing input to CMS
on the selection of certain categories of quality and efficiency
measures, as required by section 1890A(a)(3) of the Act. By February
1st of each year, the NQF must provide that input to CMS. Input from
the MAP is located at: (https://www.qualityforum.org/Setting_Priorities/Partnership/Measure_Applications_Partnership.aspx). For
more details about the pre-rulemaking process, see the FY 2013 IPPS/
LTCH PPS final rule (77 FR at 53376 (August 31, 2012)).
We also take into account national priorities, such as those
established by the National Priorities Partnership at (https://www.qualityforum.org/npp/), the HHS Strategic Plan https://www.hhs.gov/secretary/about/priorities/priorities.html), and the National Strategy
for Quality Improvement in Healthcare located at (https://www.healthcare.gov/news/reports/nationalqualitystrategy032011.pdf). To
the extent practicable, we have sought to adopt measures that have been
endorsed by the national consensus organization, recommended by multi-
stakeholder organizations, and developed with the input of providers,
purchasers/payers, and other stakeholders.
As stated in the August 4, 2011 FY 2012 Hospice Wage Index final
rule (76 FR 47302, 47320), to meet the quality reporting requirements
for hospices for the FY 2014 payment determination as set forth in
section 1814(i)(5) of the Act, we finalized the requirement that
hospices report two measures:
An NQF-endorsed measure that is related to pain
management, NQF 0209. The data collection period for this
measure was October 1, 2012 through December 31, 2012, and the data
submission deadline was April 1, 2013. The data for this measure are
collected at the patient level, but are reported to CMS in the
aggregate for all patients cared for within the reporting period,
regardless of payer.
A structural measure that is not endorsed by NQF:
Participation in a Quality Assessment and Performance Improvement
(QAPI) program that
[[Page 48256]]
includes at least three quality indicators related to patient care. The
data collection period for this measure was October 1, 2012 through
December 31, 2012, and the data submission deadline was January 31,
2013. Hospices are not asked to report their level of performance on
these patient care related indicators, but simply to indicate that a
QAPI program with patient care related indicators has been implemented.
Hospices failing to report quality data before the specified
deadline in 2013, will have their market basket update reduced by 2
percentage points in FY 2014. Hospice programs will be evaluated for
purposes of the quality reporting program based on whether or not they
submit data, and not based on their performance level on required
measures.
For the FY 2014 payment determination, hospices were asked to
provide identifying information, and then complete a web based data
entry for the required measures. For hospices that could not complete
the web based data entry, a downloadable data entry form was made
available upon request. Electronic data submission will be required for
the FY 2015 payment determination and beyond; there will be no other
data submission method available.
3. Quality Measures for Hospice Quality Reporting Program and Data
Submission Requirements for Payment Year FY 2015 and Beyond
In the November 8, 2012 CY 2013 Home Health Prospective Payment
System Rate Update final rule (77 FR 67068, 67133), to meet the quality
reporting requirements for hospices for the FY 2015 payment
determination and each subsequent year, as set forth in section
1814(i)(5) of the Act, we finalized the requirement that hospices
report two measures:
The NQF-endorsed measure that is related to pain
management, NQF 0209
The structural measure: Participation in a Quality
Assessment and Performance Improvement (QAPI) Program that includes at
least three quality indicators related to patient care. We did not
extend the requirement that hospices complete a check list of their
patient care indicators and indicate the data sources they used for
their quality indicators.
In the proposed rule for FY2014 (78 FR 27823), we proposed that the
structural measure related to QAPI indicators and the NQF 0209
pain measure would not be required for the hospice quality reporting
program beyond data submission for the FY 2015 payment determination.
The original intent of the structural measure was for hospices to
submit information about number, type, and data source of quality
indicators used as a part of their QAPI Program. Data gathered as part
of the structural measure were used to ascertain the breadth and
context of existing hospice QAPI programs to inform future measure
development activities including the data collection approach for the
first year of required reporting (the reporting period which could
result in payment reductions in FY 2014). To date, hospices have
reported two cycles worth of structural measure data to CMS:
Voluntary reporting period (submitted to CMS by January
31, 2012)--For the voluntary reporting period hospices submitted free
text data describing each quality indicator in their QAPI programs;
data regarding number and data source of quality indicators were also
submitted.
FY 2014 (submitted to CMS by January 31, 2013)--For the FY
2014 cycle, hospices submitted data about the topic areas of care
addressed by quality indicators in their QAPI Programs, using a drop-
down menu checklist rather than free text, in order to reduce burden.
Data regarding number and data source of quality indicators were also
submitted. CMS has analyzed data from both reporting periods. Findings
from the voluntary reporting period showed that hospices use quality
indicators that address a wide range of patient care related topics and
that there is great variation in how hospices collect and use
``standardized'' quality indicators. The majority of reported
indicators addressed patient safety and physical symptom management.
Likewise, findings from analysis of the FY 2014 structural measure data
reiterated findings from the voluntary reporting period.
Other topics addressed included management of psychosocial aspects
of care, bereavement and grief, communication, and care coordination.
Overall, findings from both data collections of the structural measure
have provided adequate information on hospice's patient care-related
indicators making further reporting on the structural measure
unnecessary.
Comment: We received several comments in favor of the proposal to
remove the structural measure requirement beyond data submission for
the FY 2015 payment determination. There were no comments in opposition
to removing the structural measure requirement after FY 2015. One
commenter indicated that CMS should make clear that it was only
removing the structural measure requirement, not the QAPI program
requirement from the Conditions of Participation.
Response: The results of the voluntary reporting period and the
analysis of the FY 2014 structural measure data provided adequate
information about hospices' patient care-related quality indicators. We
are finalizing the proposal to remove the structural measure
requirement beyond data submission for the FY 2015 payment
determination. We are reiterating that the requirements regarding QAPI
in the Conditions of Participation remain intact.
As stated above, in the proposed rule, we proposed that the NQF
0209 pain measure not be required for the hospice quality
reporting program beyond data submission for the FY2015 payment
determination. We determined that the NQF 0209 measure as it
is currently collected and reported by hospices is not suitable for
long term use as part of the Hospice Quality Reporting Program (HQRP).
In making this decision, we considered findings from the Voluntary
Reporting Period and the Hospice Item Set pilot. Since the publication
of the proposed rule, we examined data from the first year of reporting
on the measure (impacting FY 2014 APU determination). In addition, we
considered stakeholder input including comments submitted during
rulemaking, expert input from a Technical Expert Panel (TEP), and
provider questions and comments submitted to the hospice quality help
desk during the 2012/2013 data collection and reporting period. There
are two central concerns with the NQF 0209 measure. First, the
measure does not easily correspond with the clinical processes for pain
management, resulting in variance in what hospices collect, aggregate,
and report. This concern could potentially be addressed by extensive
and ongoing provider training or standardizing data collection.
However, even with extensive training and the use of a standardized
item set during the pilot test, the data showed continued variance in
implementation of the measure. Second, there is a high rate of patient
exclusion due to patient ineligibility for the measure and patients'
denying pain at the initial assessment. This high rate of patient
exclusion from the measure results in a small denominator and creates
validity concerns. These concerns cannot be addressed by training or
standardizing data collection. We recognize the value of measuring
hospices' ability to achieve patient comfort and the desire to include
a patient outcome measure such
[[Page 48257]]
as the NQF 0209 in the HQRP. By removing the requirement that
hospices submit the NQF 0209 measure, pain comfort will not be
measured as part of the HQRP. However, we plan to require that hospices
collect data on two other measures that address care for pain. The
standardized item set that CMS has developed contains data elements to
collect 7 quality measures endorsed by NQF for hospice. Among these are
two process measures related to pain: the NQF 1634, Pain
Screening, and NQF 1637, Pain Assessment. However, while these
measures provide insight about screening and assessment of patients,
they do not offer information about patient-reported comfort related to
pain.
In the proposed rule, an alternative proposal was made to retain
NQF 0209 until a more suitable outcome measure was available
for use in the HQRP, to maintain a focus on achieving patient comfort.
We also recognize the importance of adherence to standardized data
collection specifications when producing measures for public reporting.
We intend to work toward the HQRP's future inclusion of an improved
pain outcome measure. We solicited comment on the removal of the
checklist and data source questions from the structural measure, and
the removal of the NQF 0209 measure. We also solicited comment
on the alternative proposal of maintaining NQF 0209 until
another pain outcome measure is available.
Comment: A large majority of comments received agreed with the
proposal to remove the NQF 0209 pain measure from the HQRP
because of the concerns with the measure as described above. Commenters
stated that the measure is difficult to implement and does not
correspond with clinical processes for pain management. One commenter
suggested that there is not an issue with the data collection not
corresponding to hospice clinical practice, but rather a learning curve
phenomenon. Commenters also agreed that high rates of patient exclusion
from the measure lead to validity issues. The majority of commenters
were also against the alternate proposal to retain the NQF
0209 until an alternate pain outcome measure is developed,
citing that continuing to collect it would be an unnecessary burden on
providers. Some also commented that discontinuing data collection for
the NQF 0209 pain measure after the CY 2013 data collection
period would permit hospices more time to focus on preparing for the
implementation of the Hospice Item Set (HIS) and other requirements. A
few commenters indicated that the NQF 0209 should be retained.
Commenters in favor of retaining the measure stated that, though
flawed, the measure has merit because it is an outcome measure. They
also felt it has merit because it incorporates patient preferences for
pain management and is meaningful to consumers. Commenters also stated
that hospices invested a lot of time and energy to establish their data
collection and submission processes for this measure. One commenter
thought CMS should evaluate additional quarters of data submissions by
hospices to fully evaluate the measure's validity before deciding
whether to eliminate its use from the HQRP.
Response: Since the release of the proposed rule, we have analyzed
the NQF 0209 pain measure data from the FY 2014 hospice
reporting cycle. Results from the analysis support our central concerns
with the NQF 0209 pain measure as stated above. Due to
exclusions, a very small percentage of patients admitted to hospice
would be represented by this quality measure, suggesting validity
issues with the measure. FY 2014 data analysis shows that data errors
affected approximately one-third of all hospices' data submissions
despite the use of warning and error messages in the data submission
system. In addition, the data showed that approximately 30 percent of
the patients who were asked the initial comfort question ended up in
the measure denominator (the denominator is set by patients who said
``yes'' to the initial comfort question). The data also showed that
approximately 54 percent of hospices had 10 or fewer admissions during
the data collection period (Q4 2012), indicating a denominator size
problem that would affect the potential use of the measure for public
reporting purposes in the future. We will post a document summarizing
the findings related to the NQF 0209 measure on the cms.gov
Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/. The
document includes findings from the Voluntary Reporting Period, the
Hospice Item Set Pilot Test, and the FY 2014 national reporting of the
NQF 0209 data. These three sources of information along with
stakeholder comments during the public comment period were considered
in finalizing the proposal to discontinue the requirement that hospices
report the NQF 0209 measure beyond FY 2015. We understand that
hospices may choose to use the NQF 0209 as part of their
ongoing quality improvement efforts. However, we believe that
continuing to require hospices to report the NQF 0209 measure
beyond FY 2015 is inappropriate and burdensome. We agree that outcome
measures are essential to the HQRP. We are committed to developing an
improved pain outcome measure and we will work toward the HQRP's future
inclusion of an improved pain outcome measure. Although we appreciate
the value of including an outcome measure as part of the HQRP, based on
the majority of comments received and FY 2014 NQF 0209 data
analysis findings, we are finalizing the proposal to discontinue use of
the NQF 0209 pain measure after FY 2015 reporting. We will not
finalize the alternate proposal to retain the NQF 0209 until
another pain outcome measure is available.
4. Quality Measures for Hospice Quality Reporting Program for Payment
Year FY 2016 and Beyond
As stated in the November 8, 2012 CY 2013 Home Health Prospective
Payment System Rate Update final rule (77 FR 67068, 67133), we
considered an expansion of the required measures to include additional
measures endorsed by NQF. We also stated that to support the
standardized collection and calculation of quality measures, collection
of the needed data elements will require a standardized data collection
instrument. We have developed and tested a hospice patient-level item
set to be used by all hospices to collect and submit standardized data
items about each patient admitted to hospice. We contracted with RTI
International to support the development of the Hospice Item Set (HIS)
for use as part of the HQRP. In developing the HIS, RTI focused on the
NQF endorsed measures that had evidence of use and/or testing with
hospice providers. Most of these measures were initially developed
during the PEACE (Prepare, Embrace, Attend, Communicate, and Empower)
Project, which was funded by CMS to develop and test an initial set of
quality measures for use in hospice and palliative care. The PEACE
project, which ended in 2008, resulted in the identification of
recommended quality measure and data collection tools that hospice
providers could use in their Quality Assessment and Performance
Improvement (QAPI) programs to assess quality of care and target areas
for improvement. Additional information on the PEACE project can be
found at https://www.thecarolinascenter.org/default.aspx?pageid=24.
Most of the measures endorsed by NQF are already widely in use by
[[Page 48258]]
hospices nationwide as part of their internal Quality Reporting and
Performance Improvement (QAPI) programs. Data we received from hospices
during the Voluntary Reporting Period in 2011 showed that hospices had
implemented and were using the PEACE measures. Some of the PEACE
measures were endorsed by NQF in February, 2012, and are listed below
with their NQF endorsement numbers. The HIS standardizes the collection
of the data elements that are needed to calculate seven of the NQF
endorsed measures. The HIS was pilot tested during the early summer of
2012. The primary objective of the pilot was to explore data collection
methods and the feasibility of implementing a patient-level item set
for possible future use as part of the HQRP.
In developing the standardized HIS, we considered comments offered
in response to the July 13, 2012 CY 2013 Home Health Prospective
Payment System Rate Update proposed rule (77 FR 41548, 41573). We have
included data items that support the following NQF endorsed measures
for hospice:
NQF 1617 Patients Treated with an Opioid who are
Given a Bowel Regimen
NQF 1634 Pain Screening
NQF 1637 Pain Assessment
NQF 1638 Dyspnea Treatment
NQF 1639 Dyspnea Screening
NQF 1641 Treatment Preferences
NQF 1647 Beliefs/Values Addressed (if desired by the
patient) (modified)
To achieve a comprehensive set of hospice quality measures
available for widespread use for quality improvement and informed
decision making, and to carry out our commitment to develop a quality
reporting program for hospices that uses standardized methods to
collect data needed to calculate quality measures, we proposed the
implementation of the HIS in July 2014. We believe that to support the
standardized collection and calculation of any or all of the hospice
quality measures listed above, it is necessary to use a standardized
data collection mechanism. The HIS was developed specifically for this
data collection purpose. The HIS Paperwork Reduction Act (PRA) package
is posted on the PRA area of the CMS.gov Web site at: https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/.
We proposed that hospices begin the use and submission of the HIS
in July 2014. To meet the quality reporting requirements for hospices
for the FY 2016 payment determination and each subsequent year, we
proposed regular and ongoing electronic submission of the HIS data for
each patient admitted to hospice on or after July 1, 2014, regardless
of payer. Hospices will be required to complete and submit an admission
HIS and a discharge HIS for each patient. Hospices failing to report
quality data via the HIS in 2014 will have their market basket update
reduced by 2 percentage points in FY 2016. Hospice programs will be
evaluated for purposes of the quality reporting program based on
whether or not they submit data, not on their performance level on
required measures.
Comment: We received comments that were supportive of the
implementation of the Hospice Item Set (HIS). Commenters agreed with
the need for a standardized item set to collect patient level
information that could be used to calculate the quality measures
endorsed by the National Quality Forum (NQF) for hospice. However,
commenters were concerned that the proposed July 1, 2014 date for
starting submission of the HIS was too soon, and didn't allow for
adequate time to prepare processes and systems for data collection,
staff training, and other organizational preparations for
implementation, particularly in the context of the other proposals in
the rule such as the implementation of the hospice experience of care
instrument. Commenters noted that vendors would have less than 12
months to create software for providers to use to submit the HIS data.
Commenters were concerned that there were too many changes coming in
too short a time.
Response: We appreciate the general support of standardized data
collection and the Hospice Item Set (HIS). We are aware of the effort
hospices and vendors will have to make to prepare for implementation of
the HIS. The HIS pilot showed that implementing the HIS is feasible,
and that hospices are most likely already collecting the information
needed to complete the HIS data items. A draft version of the HIS
technical data specifications was posted on the CMS Web site on May 24,
2013. Based on other provider settings (for example, Home Health
Agencies and Nursing Homes), it is our experience that when there are
changes to the draft version of data specification the changes are
minor and few, if any, compared to the final version of the technical
data specifications. Thus, vendors have been provided with more than
adequate time (greater than 12 months) to develop products for their
clients. We expect vendors to begin reviewing the draft technical data
specifications as soon as they are posted. We encourage vendors to
submit questions and comments to the HIS technical email box:
HospiceTechnicalIssues@cms.hhs.gov. On July 16, 2013, CMS held a call
specific for software developers and vendors regarding the HIS
technical data specifications. We will hold additional vendor calls as
needed to ensure that software vendors have the appropriate information
to develop their own products for HIS. Software vendors should not be
waiting for final technical data specifications to be posted to begin
development of their own products. Therefore, we believe that vendors
have been provided with adequate time and resources to meet the July 1,
2014 implementation date of the HIS.
CMS will provide free software for the HIS. We will make a beta
version of the software available in May 2014 and the final version in
June 2014. Providing a beta version for hospice agencies to download in
May will allow their staff to become familiar with the functionality of
the tool. We will provide training on the CMS HIS software and the
submission process. We anticipate the training to occur in the spring
of 2014. Furthermore, in cases where a hospice has purchased vendor
software and the product is not available by July 1, 2014, the hospice
may download the CMS software and submit records to the Quality
Improvement and Evaluation System (QIES) Assessment and Submission
Processing (ASAP) system as required. Thus, hospices will be able to
comply with the July 1, 2014 implementation date of the HIS. We are
finalizing implementation of the HIS on July 1, 2014.
Comment: Several commenters expressed concern over the ``100
percent submission requirement'' of the HIS and stated that exceptions
for natural disasters and other extenuating circumstances should be
allowed. In addition, a few commenters expressed concern that a hospice
would be penalized if even one submission was missed, and that there
needs to be a receipt process that would provide proof of data
submission.
Response: Submission of the HIS on all patients admitted to
hospice, regardless of payer, is expected. As is common in other
quality reporting programs, we will propose to make accommodations in
the case of natural disaster or other extenuating circumstances in next
year's rulemaking. In addition, the data submission system will include
validation and receipt processes that will serve as evidence of
submission.
[[Page 48259]]
Comment: Some commenters indicated that they support the
implementation of the HIS and the endorsed measures that can be
calculated from the items on the HIS. However, while overall supportive
of the measures and the HIS, they also indicated concern about the
length of stay exclusion in the endorsed measures that will be
calculated from the HIS. Commenters were also concerned that there were
no outcome measures that will be calculated from the HIS. We also
received a few comments indicating concern over other measure
specifications (for example, additional exclusions for measures).
Response: To comply with the requirements of the Affordable Care
Act, CMS seeks to implement meaningful quality measures with
demonstrated scientific acceptability that have been endorsed by an
endorsing body, currently the NQF. Thus, we are somewhat, but not
completely constrained by the availability of endorsed hospice quality
measures. In addition, in selecting and implementing measures, we are
constrained by the measures specifications of the endorsed measures.
All of the measures that will be implemented are endorsed with a 7-day
length of stay exclusion as part of the measure specifications. Section
1841(i)(5)(D) of the Act requires us to be deferential to measures
approved by an endorsing body such as the NQF. However, we agree that
the length of stay exclusion in particular is of concern because it
effectively excludes an important segment of hospice patients from the
measures. We plan to analyze HIS data to continue to assess the
scientific acceptability of the measures and are willing to work with
measure developers and stewards to make modifications to measures where
needed. In addition, we support the development of additional hospice
quality measures, particularly outcome measures, and will seek
opportunities to use outcome measures as they are developed and
validated.
Comment: We received a few comments indicating concern over the
potential burden of the HIS on patients and families.
Response: The HIS is a set of data elements that can be used to
calculate 7 NQF endorsed quality measures. The HIS is not a patient
assessment and it will not be administered to the patient and/or family
or caregivers during the initial assessment visit. The HIS is not
intended to replace a hospice's current initial patient assessment. The
HIS pilot demonstrated that hospices use a variety of patient
assessment forms during the initial patient assessment; all hospices
were able to crosswalk items from their patient assessment forms to the
HIS data elements, and complete the HIS items. Therefore, the HIS did
not add items to the hospice's customary patient initial assessment,
and did not present an additional burden to the patient and/or family
or caregivers.
Comment: A few commenters suggested removing the discharge HIS,
indicating that the items on the discharge HIS are only administrative,
and provide no additional value in terms of the quality measures while
adding burden of completion to the hospice. Other commenters indicated
that they were pleased to see the proposal of an admission and
discharge HIS.
Response: The discharge HIS is needed to provide an end date for
the episode of care, and to establish the length of stay exclusion for
patients whose hospice stay was less than 7 days. The discharge HIS
items are minimal, but necessary for accurate records in the CMS data
system and potentially for the providers' use with their own QAPI
activities. Vendor software would pre-populate the majority of these
items and the hospice would only code a few of the items on the
discharge HIS; burden on hospices would be reduced as a result.
Comment: A few commenters voiced concerns about potential ceiling
effects with the NQF quality measures stating that measures may ``top
out.'' Two commenters stated that NQF 1634 Pain Screening
should not be considered for use in the quality reporting program,
citing concerns about ceiling effects with the measure.
Response: We recognize the commenters' concerns about the
appropriateness of use of quality measures that have ``topped out,''
demonstrating ceiling effects. Ceiling effects on quality measures
would indicate that there is little room for improvement on the
particular quality measures across providers, rendering the measures of
little use in measuring quality. There is currently no national data
available to determine whether any of the proposed measures demonstrate
ceiling effects. We will analyze data submitted to determine validity
and reliability of measures, and part of this analysis will include
analyzing for ceiling effects. We will determine appropriateness of
measures for retention in the quality reporting program based on these
analyses. We appreciate commenters' concerns about NQF 1634
Pain Screening. However, NQF 1634 Pain Screening and NQF
1637 Pain Assessment are paired measures meaning NQF
1634 is necessary to generate the denominator for NQF
1637.
Comment: Two comments stated that items for the NQF 1641
and 1647 should appear on the discharge HIS to meet measure
specifications.
Response: The NQF 1641 measure endorsement form does not
specify a time window for the measure numerator. The commenters are
correct that the NQF 1647 measure endorsement form does
specify that the numerator criteria can be met any time during the
period the patient is enrolled in the hospice program. We have
consulted NQF about our proposal to capture the data on the admission
HIS, and have received guidance that by limiting the time window in
this way, we are proposing to use a ``modification of the NQF
1647'' measure. We have opted to include the relevant items
for both the NQF 1641 and the NQF 1647 on the
Admission HIS, even though the measure specifications for the NQF
1647 permit the numerator condition to be met at any time
during the hospice episode of care. For multiple reasons, CMS has opted
to include the NQF 1647 measure items as part of the Admission
HIS, reflecting the initial period of time the patient is in hospice
care. Addressing patients' values/beliefs and preferences for treatment
by providing an opportunity for patients and families to discuss their
preferences during the comprehensive assessment period is an important
step in ensuring the delivery of hospice care that is patient and
family-centered. Including the NQF 1647 measure items as part
of the Admission HIS also aligns with the Conditions of Participation
for hospices at Sec. 418.54(c), which state that the comprehensive
assessment ``must identify the physical, psychosocial, emotional and
spiritual needs related to the terminal illness that must be addressed
in order to promote the hospice patient's well-being, comfort, and
dignity throughout the dying process. . . .'' We recognize that the
discussion can take place at any time in the course of a patient's
hospice care but believe the patient should be offered the opportunity
to address these concerns in the early days of care when they are more
likely to be able to do so. We consider it best practice. We have
chosen this approach also because it allows the gathering of the data
for the measure closer to ``real time'' in terms of usual hospice
assessment and workflow and because this approach will likely improve
accuracy and reduce burden to the provider. If these items were on the
discharge HIS, hospices would have to review the entire episode of care
documentation to find the
[[Page 48260]]
information needed to complete the relevant items on the HIS. We worked
with the measure developer to ensure that the intent of the measure is
still met with the HIS admission data collection. We will monitor the
performance over time to inform future evaluation for maintenance of
the measure's endorsement. We will proceed with the collection of the
NQF 1641 measure and the modified NQF 1647 measure as
part of the Admission HIS.
Comment: We received a few comments regarding what should count
towards the numerator for NQF 1641 (Treatment Preferences).
Commenters suggested that review of advance directives count in the
numerator for these items.
Response: Discussion of patient preferences is important to ensure
that care is individualized, patient and family centered, and
consistent with patient and/or family preferences. The intent of the
NQF 1641 measure is to ensure that hospices engage patients
and families in opportunities to discuss their treatment preferences.
Hospices meet the 1641 numerator requirements by asking the
patient and/or family about their preferences and documenting that a
discussion of preferences occurred, or by documenting that the patient
and/or family did not wish to discuss their preferences. The measure
endorsement forms clearly state that the measure is meant to capture
evidence of communication and discussion. Prior to implementation of
the HIS, we will provide hospices with guidance and training materials,
including a detailed user guide.
Comment: We received a comment that NQF 1641 (Treatment
Preferences) does not mention cardiopulmonary resuscitation (CPR) or
hospitalization.
Response: The measure specifications as endorsed by NQF do not
clearly define what constitutes preferences for life-sustaining
treatment. As such, we included data items F2000 (CPR Preference) and
F2200 (Hospitalization Preference) in the HIS to provide clarification
and improve usability. These specifics are important to measure
maintenance and development and does not stray from the measure
specifications. We will provide guidance and training materials,
including a detailed user guide for hospices prior to implementation of
the HIS.
Comment: For NQF 1647, one commenter questioned which
hospice staff would be eligible to ask the patient about concerns
related to beliefs and values to satisfy the numerator for the measure.
This commenter questions if a social worker or bereavement staff member
could collect the data or if it had to be a chaplain.
Response: The measure specifications for NQF 1647 require
documentation of a discussion between the patient and/or family and a
member of the interdisciplinary team or clergy or pastoral worker, or
documentation that the patient/family declined to discuss. We will
provide guidance and training materials, including a detailed user
guide, to hospices prior to implementation of the HIS.
Comment: We received comments providing input about specific items
on the HIS. Commenters offered suggestions on items in Sections A, F,
I, J, N, and Z of the HIS.
Response: We appreciate the comments received about specific items
in the HIS. The items in Section A are a subset of those that appear
and are standardized across data submission vehicles in multiple CMS
quality reporting programs; they are needed for adequate record
identification in CMS systems. Items in Sections F, I, J, and N are all
necessary to establish the numerator and/or denominator; meet other
measure specifications for the 7 NQF endorsed measures that can be
calculated from the HIS; or for purposes of future potential risk
adjustment to the measures.
Comment: We received several comments regarding who the hospice
must speak with about items in Section F (Preferences) to meet the
numerator condition for the corresponding measures. A few commenters
noted that not all patients have caregivers.
Response: For items F2000, F2100, and F2200, the hospice must ask
the patient or the patient's representative if the patient is unable to
self-report. The responsible party may or may not be a family member or
caregiver. We will provide guidance and training materials, including a
detailed user guide to hospices prior to implementation of the HIS.
Comment: We received several comments regarding Section I (Active
Diagnoses) and item I0010 (Principal Diagnosis) that appears in this
section. Some commenters felt the item did not include enough diagnoses
to be useful and that principal diagnoses was not relevant to the
measures. One commenter suggested that we obtain this data from claims
or Program for Evaluating Payment Patterns Electronic Report (PEPPER)
reports.
Response: Disease processes and conditions impact service delivery.
Cancer and dementia/Alzheimer's Disease are two of the most common
principal diagnoses among hospice patients. We believe that this item
is important for measure maintenance and development. The HIS applies
to all payers, which is why CMS is not relying on claims or other
available data sources. To limit the burden on hospice providers we
chose to limit the diagnostic categories.
Comment: We received comments that J0900 (Pain Screening) and J0910
(Comprehensive Pain Assessment) went beyond the measures specifications
for NQF 1634 and NQF 1637. Some commenters did not
understand the purpose of J0900D (the patient's pain severity rating);
others argued that J0900D should be removed from the item set because
it incorrectly implies that a clinician's opinion of pain severity is
an acceptable datum. Others questioned the inclusion of J0910C
(Comprehensive Pain Assessment included).
Response: The NQF 1634 and 1637 are ``paired measures''.
The NQF 1634 forms the denominator for the NQF 1637
measure. The measure specifications for NQF 1634 require that
patients must be screened for the presence or absence of pain (and if
present, a rating of its severity) using a standardized tool. The
measure specifications do not require hospices to use one particular
tool or clinical approach, in recognition of prior stakeholder input
that indicated it is important to allow clinicians to select and use
the appropriate screening tool on a case-by-case basis. The HIS is not
a patient assessment; it is an item set designed to collect data
elements that can be used to calculate NQF endorsed measures, including
NQF 1634 and 1637. As a result, item J0900D is needed
to establish whether or not the standardized screening tool selected
and used by the clinician indicated that the patient had pain. Details
of how to code item J0900D will be provided in the User Guide. CMS has
involved the measure steward in developing that User Guide. J0900 D is
also needed because it forms the denominator for NQF 1637,
pain comprehensive assessment. The measure specifications for NQF
1637 indicate that a comprehensive clinical assessment should
include 5 of the following 7 characteristics of pain: location,
severity, character, duration, frequency, what relieves or worsens the
pain, and the effect on function or quality of life. J0910C provides a
checklist of these 7 items and forms the numerator for NQF
1637.
Comment: We received several comments regarding J0900 (Pain
Screening) and J0910 (Pain Assessment). Some commenters expressed that
we
[[Page 48261]]
should provide more clarity on acceptable pain screening tools and
determining patient pain severity. Regarding J0910C (Comprehensive Pain
Assessment included), one commenter indicated that finding the elements
of the comprehensive pain assessment in the medical record would be
tedious.
Response: The measure specifications for NQF 1634 (Pain
Screening) require that patients must be screened for the presence or
absence of pain (and if present, a rating of its severity) using a
standardized tool. The HIS is not a patient assessment, and we do not
want to be overly prescriptive in which standardized pain screening
tools hospices use or how patient pain is rated. Thus, the items listed
in J0900C (Type of standardized pain screening tool used) are not
specific screening tools in and of themselves. Instead they are tools
that may be utilized for the assessment of pain severity. Item J0910C
(Comprehensive pain assessment included) helps form the numerator for
NQF 1637 (Pain Assessment) and must be retained. We will
provide guidance and training materials, including a detailed user
guide to hospices prior to implementation of the HIS.
Comment: We received comments on J2030 (Screening for Shortness of
Breath) and J2040 (Treatment for Shortness of Breath). One commenter
suggested that the respiratory screening should require evaluation of
shortness of breath upon exertion. Another commenter questioned the
purpose of J2040C (Type(s) of treatment for shortness of breath
initiated).
Response: The measure specifications for NQF 1639 (Dyspnea
Screening) do not require that the respiratory screening include
evaluation upon exertion. J2040C helps form the numerator for NQF
1639. We believe that this item will improve usability by
indicating the treatments/types of treatment that may be considered
treatment for shortness of breath for purposes of the measure numerator
condition. The HIS is not a patient assessment, and we do not want to
be overly prescriptive in which screening tools hospices use,
particularly for shortness of breath where there is no accepted
standardized screening or assessment tool. We will provide guidance and
training materials, including a detailed user guide to hospices prior
to implementation of the HIS.
Comment: One commenter wanted to know when N0520 (Bowel Regimen)
required a response.
Response: As noted on the draft HIS, providers will respond to the
bowel items if a scheduled opioid and/or a PRN opioid is initiated or
continued.
Comment: We received several comments related to Section Z (Record
Administration), particularly item Z0400 (Signature(s) of Person(s)
Completing the Record). Commenters were unclear on the purpose of this
section and how Z0400 should be completed.
Response: The items in Section Z appear in and are standardized
across data submission vehicles in multiple CMS quality reporting
programs. This section allows providers to verify, internally, the
individuals responsible for completing the HIS (that is the
abstracters, not those completing the patient assessment). In
accordance with processes used in other care settings, it is suggested
that the signature page of Section Z be retained by the hospice in
accordance with the hospice's policies and procedures related to
patient information and clinical records.
Comment: Several commenters inquired about future guidance and
training on the HIS.
Response: We will provide guidance and training materials,
including a detailed user guide, to hospices prior to implementation of
the HIS. We plan to provide Hospices with further information and
details about use of the HIS. We will provide this information through
venues such as postings on the Hospice Quality Reporting Program Web
page, Open Door Forums, announcements in the CMS E-News, provider
training, and National Provider calls. Electronic data submission will
be required for HIS submission in CY 2014 and beyond; there will be no
other data submission method available. We will make available
submission software for the HIS to hospices at no cost. We will also
provide reports to individual hospices on their performance on the
measures calculated from data submitted via the HIS. The specifics of
the reporting system and precisely when specific measures will be made
available have not yet been determined. We will report to providers on
the following measures on a schedule to be determined:
NQF 1617 Patients Treated with an Opioid who are
Given a Bowel Regimen
NQF 1634 Pain Screening
NQF 1637 Pain Assessment
NQF 1638 Dyspnea Treatment
NQF 1639 Dyspnea Screening
NQF 1641 Treatment Preferences
NQF 1647 Beliefs/Values Addressed (if desired by the
patient)
Table 6--Summary Tables
----------------------------------------------------------------------------------------------------------------
Data collection Data submission APU Impact Measure name
----------------------------------------------------------------------------------------------------------------
Finalized in the CY 2013 HH PPS Final Rule
----------------------------------------------------------------------------------------------------------------
1/1/2013-12/31/2013................ 4/1/2014............... FY 2015 (10/1/2014)... Structural/QAPI measure
NQF 0209.
----------------------------------------------------------------------------------------------------------------
Finalized in this Final Rule
----------------------------------------------------------------------------------------------------------------
7/1/2014-12/31/2014................ Rolling................ FY 2016 (10/1/2015)... Hospice and Palliative
Care--Pain Screening, NQF
1634.
7/1/2014-12/31/2014................ Rolling................ FY 2016 (10/1/2015)... Hospice and Palliative
Care--Pain Assessment,
NQF 1637.
7/1/2014-12/31/2014................ Rolling................ FY 2016 (10/1/2015)... Hospice and Palliative
Care--Dyspnea Screening,
NQF 1639.
7/1/2014-12/31/2014................ Rolling................ FY 2016 (10/1/2015)... Hospice and Palliative
Care--Dyspnea Treatment,
NQF 1638.
7/1/2014-12/31/2014................ Rolling................ FY 2016 (10/1/2015)... Patients Treated with an
Opioid who are Given a
Bowel Regimen, NQF 1617.
7/1/2014-12/31/2014................ Rolling................ FY 2016 (10/1/2015)... Hospice and Palliative
Care--Treatment
Preferences, NQF 1641.
7/1/2014-12/31/2014................ Rolling................ FY 2016 (10/1/2015)... Beliefs/Values Addressed
(if desired by patient),
modified NQF 1647.
----------------------------------------------------------------------------------------------------------------
[[Page 48262]]
As stated in the August 4, 2011 FY 2012 Hospice Wage Index final
rule (76 FR 47302, 47320), we finalized that all hospice quality
reporting periods subsequent to that for Payment Year FY 2014 will be
based on a CY instead of a calendar quarter and for FY 2015 and beyond,
the data submission deadline will be April 1st of each year. The
implementation of the HIS in July 2014 will negate the CY data
collection requirement and the April 1st data submission deadline. We
will provide details on data collection and submission timing prior to
implementation of the HIS.
5. Public Availability of Data Submitted
Under section 1814(i)(5)(E) of the Act, the Secretary is required
to establish procedures for making any quality data submitted by
hospices available to the public. The procedures ensure that a hospice
will have the opportunity to review the data regarding the hospice's
respective program before it is made public. In addition, under section
1814(i)(5)(E) of the Act, the Secretary is authorized to report quality
measures that relate to services furnished by a hospice on the CMS Web
site. We recognize that public reporting of quality data is a vital
component of a robust quality reporting program and are fully committed
to developing the necessary systems for public reporting of hospice
quality data. We also recognize it is essential that the data made
available to the public be meaningful and that comparing performance
between hospices requires that measures be constructed from data
collected in a standardized and uniform manner. The development and
implementation of a standardized data set for hospices must precede
public reporting of hospice quality measures. Once hospices have
implemented the standardized data collection approach, we will have the
data needed to establish the scientific soundness of the quality
measures that can be calculated using the standardized data collection.
It is critical to establish the reliability and validity of the
measures prior to public reporting in order to demonstrate the ability
of the measures to distinguish the quality of services provided. To
establish reliability and validity of the quality measures, at least
four quarters of data will need to be analyzed. Typically the first two
quarters of data reflect the learning curve of the providers as they
adopt a standardized data collection; these data are not used to
establish reliability and validity. This means that the data from Q3
and Q4 CY 2014 will not be used for assessing validity and reliability
of the quality measures. Data collected by hospices during Q 1, 2 and 3
CY 2015 will be analyzed starting in CY 2015. Decisions about whether
to report some or all of the quality measures publicly will be based on
the findings of analysis of the CY 2015 data. In addition, as noted,
the Affordable Care Act requires that reporting be made public on a CMS
Web site and that providers have an opportunity to review their data
prior to public reporting. We will develop the infrastructure for
public reporting, and provide hospices an opportunity to review their
data. In light of all the steps required prior to data being publicly
reported, we anticipate that public reporting will not be implemented
in FY 2016. Public reporting may occur during the FY 2018 APU year,
allowing ample time for data analysis, review of measures'
appropriateness for use for public reporting, and allowing hospices the
required time to review their own data prior to public reporting. We
will announce the timeline for public reporting of data in future
rulemaking. We welcome public comment on what we should consider when
developing future proposals related to public reporting.
Comment: We received a few comments regarding what should be
considered in developing future proposals related to public reporting
of hospice quality data. Commenters were in favor of public reporting,
and indicated that they felt it was time to make this information
available to consumers. Commenters also indicated that they appreciate
the opportunity to review their data prior to the initiation of public
reporting, and CMS's efforts to ensure that public reporting would not
occur before adequate data analysis had taken place to establish the
suitability of the measures for public reporting purposes. A few
commenters suggested that outcome measures and measures from the family
experiences of hospice care survey would be more meaningful for public
reporting than the measures from the HIS. Several commenters had
concerns about which of the NQF measures proposed would be appropriate
for public reporting. Commenters noted that all of the NQF measures
proposed were process measures and it may ``take effort'' for the
public to understand the relationship of process measures to quality of
care. One commenter stated that a comprehensive explanation of this
relationship should be provided to the public.
Response: We appreciate and recognize commenters' concerns about
appropriateness of quality measures for public reporting. As stated in
the proposed rule, we will analyze data for validity and reliability of
quality measures and review measures' appropriateness for public
reporting prior to determining which measures will be publicly
reported. Moreover, we appreciate the suggestion to provide a
comprehensive explanation of relationships between quality measures
selected for public reporting and quality of care. We will consider
this suggestion when developing processes, procedures and future
proposals for public reporting. We also recognize the importance of
outcome data, both for quality measurement and for public reporting. We
also reiterate that we are committed to seeking opportunities to use
outcome measures--both as part of the quality reporting program and for
public report--as they are developed and become endorsed by NQF.
6. The CMS Hospice Experience of Care Survey for the FY 2017 Payment
Determination and That of Subsequent Fiscal Years
Background
In the CY 2013 Home Health Prospective Payment System Rate Update
final rule (77 FR 67135), we stated that were considering the use of a
patient/family experience of care survey in addition to other hospice
quality of care (clinical) measures. We have developed a draft Hospice
Experience of Care Survey questionnaire drawing heavily on
questionnaires in the public domain such as the Family Evaluation of
Hospice Care (FEHC). We are testing the draft survey in a national
field test in fall 2013. The Hospice Experience of Care Survey will
treat the dying patient and his or her informal caregivers (family
members or friends) as the unit of care.
Before the development of this survey, there was no official
national standard experience of care survey that included standard
survey administration protocols. The Hospice Experience of Care Survey
will include detailed survey administration protocols which will allow
for comparisons across hospices. The survey will focus on topics that
are important to hospice users and for which informal caregivers are
the best source for gathering this information. In addition, the
``About You'' section of the instrument includes demographic
characteristics of the patients and their caregivers which can be used
to feed into case mix adjustments of the publicly reported data.
[[Page 48263]]
Description of the Survey
The Hospice Experience of Care Survey will seek information from
informal caregivers of patients who died while enrolled in hospices. We
plan to field the questionnaires after the patient's death. Fielding
timelines will be established to give the respondent some recovery time
(two to three months), while simultaneously not delaying so long that
the respondent is likely to forget details of the hospice experience.
Caregivers will be presented with a set of standardized questions about
their own experiences and the experiences of the patient in hospice
care. During national implementation of this survey, hospices will be
required to offer the survey, but individual caregivers will respond
only if they voluntarily chose to do so.
The Hospice Experience of Care Survey captures such topics as
hospice provider communications with patients and family members,
hospice provider care, and patient and family member characteristics.
The survey will allow the informal caregiver (family member or friend)
to provide an overall rating of the hospice care their patient
received, and will ask if they will recommend ``this hospice'' to
others.
The Hospice Experience of Care Survey is following the principles
used in the development of the Consumer Assessment of Healthcare
Providers and Systems (CAHPS[supreg]) surveys. Therefore, we are--
Obtaining input from consumers and stakeholders regarding
how hospice patients perceive hospice care and what elements in hospice
programs are of greatest importance to patients and informal
caregivers.
Drafting a version of the hospice questionnaire that will
be cognitively tested with a small number of respondents in both
English and Spanish. This type of testing will allow us to assess how
respondents interpret and respond to individual questionnaire items.
Providing a field test of the Hospice Experience of Care
Survey instrument after the development of an initial questionnaire is
completed. This field test will allow us to review survey
implementation procedures and use statistical analysis of the survey
results to select the final set of questions. In addition, it will
allow us to select variables which may be used in the case mix
adjustment of survey results for public reporting.
The Hospice Experience of Care Survey, as well as the CAHPS[supreg]
family of surveys, focuses on patient perspectives on the experience of
care, rather than on patient satisfaction. CAHPS[supreg] data
complements other data, including clinical measures. CAHPS[supreg]
surveys are specifically intended to focus on issues where the patient
(or in this case the caregiver) is the best source of information. We
intend the Hospice Experience of Care Survey to have a similar focus.
Once the survey is final, we will submit it for CAHPS[supreg]
endorsement and National Quality Forum endorsement.
We plan to move forward with a model of survey administration in
which we will approve and train survey vendors to administer the survey
on behalf of hospices. This will be very similar to the models that we
use for Hospital CAHPS[supreg] (HCAHPS) and Home Health CAHPS[supreg]
(HHCAHPS). Hospices will be required to contract with an approved
survey vendor and to provide the sampling frame to the approved vendor
on a monthly basis.
Participation Requirements for the Survey Begin in CY 2015 for the FY
2017 Payment
We proposed that we would begin required implementation of the
survey in January 2015 in the FY 2014 Hospice Wage Index and Payment
Rate Update; Hospice Quality Reporting Requirements; and Updates on
Payment Reform proposed rule (78 FR 27823, published May 10, 2013). We
are finalizing the proposed timeline due to the importance of the
caregiver's voice. Beginning in first quarter of CY 2015, hospices will
be required to conduct a dry run of the survey for at least one month
in January 2015, February 2015, or March 2015. Beginning in April 2015,
all hospices will be required to participate in the survey on an
ongoing basis. The one ``dry run month,'' plus the nine months of April
2015 to December 2015 participation, will be required to meet the pay
for reporting requirement of the Hospice Quality Reporting Program for
the FY 2017 annual payment update.
Approved Hospice Experience of Care Survey vendors will submit data
on the hospice's behalf to the CMS hospice patient experience of care
survey data center. The deadlines for data submission have not yet been
finalized. For the ``dry run'' the survey vendor would follow all the
national implementation procedures, but the data would not be publicly
reported. The dry run would provide hospices and their vendors with the
opportunity to work together under ``test'' circumstances. We will
allow exemptions for very small hospices. Hospices that have fewer than
50 unduplicated or unique deceased patients in the period from January
1, 2014 through December 31, 2014 will be exempt from the Hospice
Experience of Care Survey data collection and reporting requirements
for the FY 2017 payment determination. The hospices would be required
to submit their patient counts for the period of January 1, 2014
through December 31, 2014 to CMS. The due date for the participation
exemption form will be stated in next year's rule. To qualify for the
small size exemption, hospices will need to submit to CMS their patient
counts annually for each future APU period.
As part of the national implementation, we will develop technical
specifications for vendors to follow and will issue a detailed survey
guidelines manual prior to the dry run months.
In addition, there will be a Web site devoted specifically to the
Hospice Experience of Care Survey. It will include information and
updates regarding survey implementation and technical assistance.
Hospices interested in viewing similar model Web sites are encouraged
to visit the HCAHPS Web site at www.hcahpsonline.org or the HHCAHPS Web
site at https://homehealthcahps.org. On these Web sites, viewers can
see and download the detailed manuals about the surveys (the Quality
Assurance Guidelines for Hospital CAHPS[supreg] and the Protocols and
Guidelines Manual for Home Health Care CAHPS[supreg]), as well as
obtain information about the surveys' histories, data submission
information, and survey updates.
Consistent with our other implemented surveys, we will provide an
email address and toll-free telephone number for technical assistance.
The Affordable Care Act requires that beginning with FY 2014 and
each subsequent FY, the Secretary shall reduce the market basket update
by 2 percentage points for any hospice that does not comply with the
quality data submission requirements with respect to the FY. Any such
reduction would not be cumulative and would not be taken into account
in computing the payment amount for subsequent FYs. In the November 8,
2012 CY 2013 Home Health Prospective Payment System final rule (77 FR
67068), it was stated that all hospice quality reporting periods
subsequent to that for Payment Year 2014 would be based on a CY rather
than on a FY. We are finalizing adding the Hospice Experience of Care
Survey to the Hospice Quality Reporting Program requirements for the FY
2017 payment determination. To meet the FY 2017 requirements, hospices
would participate in a dry run for at least 1
[[Page 48264]]
month of the first quarter of CY 2015 (January 2015, February 2015,
March 2015) and hospices must collect the survey data on a monthly
basis for the months of April 1, 2015 through December 31, 2015 in
order to qualify for the full APU.
The following is a summary of the comments we received regarding
the Hospice Experience of Care Survey proposal.
Comment: We received a number of comments that the timeline for
implementation of the Hospice Experience of Care Survey placed it too
close in proximity to the implementation of the HIS items and that
there should be a gap of at least 12 months between the HIS
implementation and the survey implementation dates.
Response: We carefully reviewed the comments asking for a delay in
the timing of the national implementation of the Hospice Experience of
Care Survey. However, we concluded that obtaining data from caregivers
is so important that we cannot delay. As proposed we will begin with a
dry run in the first quarter of 2015. Continuous data collection will
begin April, 1, 2015 for the 2017 APU.
Comment: We received comments that there are financial and
administrative burdens on hospices participation in the Hospice
Experience of Care Survey. Commenters also stated that the financial
burden of participation would outweigh the 2 percent reduction in the
annual payment update that would be given to non-participating
hospices. We also received comments stating that this would require
more staffing and the development of a process to handle the
implementation of the survey and comments that this is a burden to
small hospices. We received a comment asking if hospices can self-
administer the survey to save costs in implementing the hospice survey.
In addition, we received a comment that the Family Evaluation of
Hospice Care (FEHC) survey does not pose a financial burden to hospices
because the FEHC survey is a benefit of National Hospice and Palliative
Care Organization (NHPCO) membership.
Response: We appreciate the comments concerning that the proposed
survey is a financial burden to participating hospices. We are using
the same survey implementation model that we use for other
CAHPS[supreg] surveys where providers pay approved survey vendors to
conduct the data collection on their behalf and CMS pays for the survey
vendor training, technical support and assistance for hospices and
their approved survey vendors, oversight of the approved survey
vendors, the public reporting of the data, and the data analysis of the
hospice survey data. Before national implementation begins in 2015,
hospices are strongly encouraged to shop around for the best cost value
for them before contracting with an approved survey vendor to conduct
the Hospice Experience of Care Survey on their behalf. Hospices cannot
self-administer the survey because we need to eliminate any potential
bias in the administration of the survey. We do not believe that the
annual burden to hospices will exceed the annual burden and costs that
we see in the implementation of HHCAHPS. Basically, once national
implementation starts, hospices will need to choose a vendor and
contract with them, and then they will be responsible on a monthly
basis to produce a file of all the caregivers (the persons on the
records for the hospice patients) for hospice patients who died in the
past month. We are not surveying people who have living hospice
patients. We cannot fully comment on whether the survey costs to the
individual hospice providers will outweigh the costs of the loss of 2
percent of the APU. However, most survey costs will be much less than
the loss of the 2 percent reduction in the APU. Small hospices serving
50 or fewer patients in an annual period will complete (annually) a
Participation Exemption Request Form so that they will not incur survey
costs. The CMS hospice survey will require the approved survey vendors
to implement the survey in accordance to a uniform set of protocols and
guidelines to assure consistency in the survey administration, in the
implementation of other CMS CAHPS[supreg] surveys, such as HCAHPS, and
HHCAHPS.
Comment: We received comments that the draft hospice experience of
care survey instrument is too long and ``daunting'' to read and respond
to.
Response: This is a survey that is going to be used in a national
field test in fall 2013. There are more questions in this test survey
than we intend to keep in the final survey. We anticipate that we will
eliminate questions that do not contribute to the composites measuring
key areas of the hospice care experience. We do anticipate keeping all
of the demographic questions, because they will be used to adjust the
results for differences in the mix of patients across hospices and for
analysis of disparities of care. It is important that the data are
adjusted to ensure accurate comparisons across hospices. We actually
anticipate that the final survey instrument will be significantly
shorter than the FEHC, which has 54 items, and a shorter instrument
will translate into lower vendor costs for the participating hospices.
To give an example of this, the field test version of the HHCAHPS
survey had 54 items and the final approved version of the survey that
we use today, has 34 items.
Comment: We received a comment expressing the preference that NHPCO
be allowed to be a survey vendor for the Hospice Experience of Care
Survey.
Response: We will be using survey vendor eligibility criteria that
are very similar or identical to our other CAHPS[supreg] surveys, and
if NHPCO meets the stated survey vendor eligibility criteria then we
welcome NHPCO to complete the survey vendor application for the hospice
experience of care survey.
Comment: We received comments that we are administering the survey
too close to the death of the patient.
Response: We thank you for this comment. We are sensitive that a
survey about this issue will be difficult for the families and friends
of their loved ones who have passed, especially in the first year
following the deaths. We anticipate administering the survey about two
or three months following the deaths of the hospice patients. We are
hesitant about waiting too long following the deaths because the survey
respondents may forget the details of the hospice experiences if the
survey is administered too long following the deaths.
Comment: We received several comments supporting CMS for developing
a new survey instrument that is independent of existing hospice survey
instruments, and that has the uniform survey implementation guidelines
of the CAHPS[supreg] surveys.
Response: We appreciate this support of the CMS survey instrument.
We are following the CAHPS[supreg] guidelines and we will apply for
CAHPS[supreg] endorsement as well as the endorsement of the National
Quality Forum. Commenters supporting us noted that the final survey
instrument will be shorter and that we will allow flexibilities in the
implementation of the survey that will allow hospices to add their own
questions, but that the core questions will be used for valid
comparisons across hospices because we will define the protocols and
guidelines for the implementation of the survey to create an equal
implementation process for the survey.
Comment: We received a comment that we cannot regulate payment
based on what the living family members think of hospice care because
it is not possible to make everyone happy and
[[Page 48265]]
asking about this experience post death seems odd and could result in a
larger percentage of negative responses.
Response: We appreciate this viewpoint. However, the survey itself
does not focus on the death. It focuses on the hospice care and the
details about the experience of care with the hospice. The survey's
purpose is to provide useful information to other caregivers and
families who are in the position of comparing hospices for the care of
their loved ones.
Comment: We received a comment that there are many family and
friends at the time of the death but that they may not be present after
the death when the survey goes out. We also received a comment that
some hospices will send out multiple surveys to family members who had
perceived good experiences, and conversely, will not send out surveys
to family members who are mentally ill, or were not involved in the
hospice patient's care, even if they were listed as the closest
relative. We received a comment that the results may be skewed by the
family member's degree of contact with the patient and hospice team.
Response: We appreciate these sensitive comments concerning who
will be the survey respondent. We propose to have a uniform standard
for the designation of the survey respondent. We propose that the
survey respondent will be the person who is listed in the hospice
record as the primary caregiver or primary contact person for the
hospice patient.
Comment: We received a comment that surveys should not be sent more
than two times to families as there is a need not to be too intrusive.
Response: For the field test, we will have one survey mode, called
the mixed mode that includes both a mail survey and telephone follow-up
for non-respondents. If the survey respondent does not return the
mailed questionnaire, then the survey respondent is called and asked to
complete the telephone survey instrument. For national implementation
of the survey, we will have three modes: Mail only, telephone only, and
mixed. For the mail only mode, only two surveys are mailed to the
sampled person. For the telephone only mode, there will be up to five
call attempts to reach the sampled respondent, but once the sampled
respondent answers the telephone and speaks with the telephone
surveyor, the respondent will only be asked to complete the survey
once.
Comment: We received comments that rural hospices will be at a
disadvantage paying for the Hospice Experience of Care Survey, and that
there should not be a 2 percent reduction since hospices save money for
Medicare.
Response: We are requiring the survey for all hospices, to meet the
goals of transparency for hospices regardless of their location. We
believe that the burden to rural and urban hospices is equal, and we
reiterate that small hospices serving 50 or fewer in a given year will
be exempt from survey participation if they complete the survey's
Participation Exemption Request form for each APU.
Comment: We received a comment asking if CMS would require the
survey to be available in other languages, such as Spanish.
Response: Vendors will be required to offer the survey in English
and Spanish. Hospices will be able to administer the survey in
additional languages if needed for their patient populations; however,
they must use the CMS official translations. We plan to make additional
translations of the survey available as needed. If you would like to
request a specific translation, please email CMS at
hospicesurvey@cms.hhs.gov.
Comment: We received a comment stating that it is not clear whether
hospices are given the full credit for survey participation regardless
of the survey results.
Response: We stated in the proposed rule that survey participation
is required for the full APU; the data results are not part of the
requirements for the APU. The survey requirement is part of the Hospice
Quality Reporting Program; this is not a pay for performance program.
Comment: We received a comment stating that their vendor for the
FEHC notifies them immediately about negative comments that are
received about their hospice. This commenter noted that there is no
information in the proposed rule that describes how the comment section
of the proposed survey will be used, or available to the hospice paying
for survey service.
Response: Hospices will still be able to have this arrangement with
their respective vendors in the CMS Hospice Experience of Care Survey.
Comment: We received a comment asking if hospices will be
responsible for a certain response rate for the Hospice Experience of
Care Survey.
Response: No, hospices will not be responsible for a certain
response rate for the Hospice Experience of Care Survey. However, all
approved survey vendors must follow the survey administration protocols
to implement the survey.
Comment: We received a comment of support for the FEHC survey and
questions about why CMS is mandating the new survey in place of the
FEHC. We also received a comment that CMS should allow the FEHC to be
substituted for the CMS Hospice Survey.
Response: We respect the work that went into the FEHC; however, we
cannot allow the FEHC to substitute for the CMS survey. To be useful to
the public, Hospice Survey data must be comparable across hospices. Two
different surveys would create inconsistencies among hospices that
would not allow for direct comparisons. In addition, the FEHC was
designed by and for a private entity. CMS must ensure that no private
entity has a preferred relationship with the agency. The CMS survey was
developed under the standards of the CAHPS[supreg] surveys and will be
implemented with the rigorous guidelines of the CAHPS[supreg] surveys.
Comment: A commenter stated that the dry run should be 3 months,
instead of 1 month.
Response: The requirement for the dry run is 1 month, but hospices
are allowed to do 2 or 3 months, in the period of January through March
2015.
Comment: We received a comment that consideration needs to be given
to the diverse audiences responding to the survey. Issues related to
primary language, socioeconomic status, culture, and health literacy,
may impact the completion of the survey and the responses to the survey
questions.
Response: We agree with this commenter and will adjust the survey
results for respondent mix. We will also be offering multiple
translations and different modes of survey administration so hospices
can choose what meets their needs the best.
Comment: We received a comment that consideration needs to be given
to the smaller agency where one negative survey can skew the data
results for that agency.
Response: For other CAHPS[supreg] surveys, we have received
comments about the comparability of the data for small providers with
large providers. In the practice of statistics, it is established that
the sample size in absolute numbers is more important than the
proportion of the population surveyed. Surveying a sample of 300 will
produce the same level of precision whether the sample large or small.
The larger the sample, the less the variability is a provider's ratings
over time. We will be proposing the required sample sizes for all
hospices in next year's proposed rule. Small agencies will need to
conduct census sampling if they do not qualify for the size exemption.
[[Page 48266]]
Comment: We received a comment that CMS needs to know what its
ultimate goal is of the surveys without losing sight of the goal
itself.
Response: The goals of the Hospice Experience of Care Survey are
the same as the goals of our other CAHPS[supreg] surveys: (1) To
produce comparable data on the caregiver's or loved one's' perspectives
on care that allow objective and meaningful comparisons between
hospices on domains that are important to consumers; (2) to create
incentives for hospices to improve their quality of care through public
reporting of survey results; and (3) to enhance public accountability
in health care by increasing the transparency of the quality of the
care provided in return for the public investments. CMS is serious
about these three goals for all of our perspectives of care/
CAHPS[supreg] surveys, and we intend to never lose sight of their
importance.
Comment: We received a comment that the first portion of the survey
is nearly identical to HHCAHPS, while the latter portion seems more
representative of hospices. This commenter stated that questions
regarding goals of care or the patient's plan of care were absent, two
areas of particular importance for hospices. This commenter also noted
that questions regarding after-hour response to needs were absent, an
area known to create much anxiety for patients and families.
Response: We reviewed both surveys side-by-side and disagree with
this commenter about the similarity to HHCAHPS. We have some similar
questions, but this is because in focus groups and later testing these
issues were all raised by our testing participants. Also, we have many
questions about care. We also have questions about after-hour response
to needs. They are: ``While your family member was in hospice care, did
you need to contact the hospice team during evenings weekends or
holidays for questions or help with your family member's care?, and
``How often did you get the help you needed from the hospice team
during evenings, weekends, or holidays?
Comment: We received a comment about transitioning from the current
FEHC program to the CMS Hospice Survey.
Response: We do not have any relationship to the FEHC program.
Hospices can continue to continue to use the FEHC. However, the FEHC
cannot be substituted for the CMS Hospice Experience of Care Survey.
Hospices can conduct both surveys under specific conditions that will
be detailed in the CMS Hospice Survey Guidelines Manual, which has not
been written.
Comment: We received a comment that the survey should meet the
quality needs of individual hospices.
Response: We hope that the survey will serve the quality needs of
all hospices. However, hospices may have unique quality needs and
hospices will be permitted to add their own additional questions to the
standardized survey.
Comment: We received comments that the caregiver of record is not
always the best person to receive the survey.
Response: We are aware the caregiver of record may not be the best
person to receive the survey. However, because the hospice is likely to
have contact information for this person, they are the best person for
us to contact.
Comment: We received comments expressing the concern that
collecting demographic information from respondents could reduce
response, especially from minority populations. In addition, commenters
said that asking for this information could raise privacy and
confidentiality concerns. We received a comment suggesting CMS redesign
the Hospice Experience of Care Survey so that there were no survey
questions about demographic characteristics. The commenter has received
feedback that no one likes to answer those kinds of questions.
Response: We ask for demographic information on surveys for two
purposes: First, to allow us to make case mix adjustments so that
hospices' survey responses can be compared fairly. We have not
determined how case mix adjustments will be calculated for this survey,
and therefore, need demographic variable to test different case mix
adjustment variables. Second, we also need demographic information to
allow for research on health care disparities between groups of people,
including minorities. All sampling data, which will include these
items, will be treated as private and confidential. The approved survey
vendors who conduct these surveys will be responsible for maintaining
the security, privacy and confidentiality of sampling information and
survey results in accordance with HIPAA requirements. Above all, the
completion of the survey is voluntary for all persons who receive the
survey in the mail, or who are telephoned and are asked to complete the
survey on the telephone. Any person who receives the survey, or who is
telephoned and is asked to complete the survey, is free not to complete
the survey.
Comment: We received a comment that the survey data should be
adjusted for length of hospice stay and for the care setting.
Response: We will use the data from the field test to determine if
the administrative data (such as length of stay and hospice setting)
has an impact on the survey data results.
Comment: We received comments that CMS should not exempt very small
rural hospices from the requirements.
Response: Besides the burden to these hospices, there is the issue
of privacy to the respondents. In very small settings, it could be
apparent who the survey respondents are. Also, there are sampling and
reliability issues because the sample and the data could be very small.
Comment: We received comments stating that it is going to be very
difficult for survey respondents to complete the survey if their loved
ones changed hospice settings.
Response: At the beginning of the survey, respondents are
instructed to reply to the questionnaire as pertaining to the last
setting of hospice care.
Comment: We received comments suggesting that CMS add questions to
the survey. The suggested topics for added items include questions
specifically relevant to veterans as well as questions about care
planning, care goals, and volunteers.
Response: One of the concerns often expressed to us is that the CMS
Hospice Experience of Care Survey is too long. We intend to shorten the
survey after the field test. In this context, we are reluctant to add
still more questions to the core survey instrument. However, we know
that it can be important for providers to ask questions that are not on
the approved core survey instrument. Hospices will be permitted to add
their own questions to the survey, following the required core set of
questions.
Comment: We had one comment that suggested the follow-up schedule
for the field test of the Hospice Experience of Care Survey was too
aggressive and would make family members or friends of the deceased
feel harassed.
Response: Our follow-up plan for the field test is very typical for
professional mixed-mode surveys. We plan to mail a survey to the sample
members. Sample members who have not responded within three weeks will
receive follow-up telephone calls. We will make up to a maximum of five
telephone calls, at different days and times, in an effort to reach the
sample member. If we have not reached the sample member after five
attempts, calls will be curtailed. If the sample member is reached but
refuses to complete the survey, no more calls will be made. We will not
[[Page 48267]]
repeatedly call the sample member and ask for a response.
Summary of Final Rule Changes for the Hospice Experience of Care Survey
As a result of these comments, we are finalizing the requirements
as proposed. Hospices must participate in and report data from a dry
run for at least 1 month in the first quarter of CY 2015 (January 2015,
February 2015, or March 2015) with continuous monthly data collection
beginning in April 1, 2015 and continuing through December 31, 2015.
7. Notice Pertaining to Reconsiderations Following APU Determinations
At the conclusion of any given quality data reporting period, we
will review the data received from each hospice during that reporting
period to determine if the hospice has met the reporting requirements.
Hospices that are found to be non-compliant with the reporting
requirements set forth for that reporting cycle could receive a
reduction in the amount of 2 percentage points to their annual payment
update for the upcoming payment year.
We are aware that there may be situations when a hospice has
evidence to dispute a finding of non-compliance. We further understand
that there may be times when a provider may be prevented from
submitting quality data due to the occurrence of extraordinary
circumstances beyond their control (for example, natural disasters). It
is our goal not to penalize hospice providers in these circumstances or
to unduly increase their burden during these times.
Other CMS Quality Reporting Programs, such as Home Health Quality
Reporting and Inpatient Quality Reporting, include an opportunity for
providers to request a reconsideration pertaining to their APU
determinations. We are aware of the potential need for providers to
request reconsideration and that we will be making APU determinations
for FY 2014 in the coming months. Therefore, to be consistent with
other established quality reporting programs, we used the proposed rule
to notify providers of our intent to provide a process that would allow
hospices to request reconsiderations pertaining to their FY 2014 and
subsequent years' payment determinations.
Specifically, as part of the reconsideration process for hospices
beginning with the FY 2014 payment determinations, hospices found to be
non-compliant with the reporting requirements during a given reporting
cycle would be notified of that finding. The purpose of this
notification is to put hospices on notice of the following: (1) That
they have been identified as being non-compliant with section 3004 of
the Affordable Care Act for the reporting cycle in question; (2) that
they would be scheduled to receive a reduction in the amount of 2
percentage points to the annual payment update to the applicable fiscal
year; (3) that they may file a request for reconsideration if they
believe that the finding of non-compliance is erroneous, or that if
they were non-compliant, they have a valid and justifiable excuse for
this non-compliance; and, (4) that they must follow a defined process
on how to file a request for reconsideration, which would be described
in the notification.
Upon the conclusion of our review of each request for
reconsideration, we would render a decision. We could reverse our
initial finding of non-compliance if: (1) The hospice provides proof of
full compliance with the all requirements during the reporting period;
or (2) the hospice was not able to comply with requirements during the
reporting period, and it provides adequate proof of a valid or
justifiable excuse for this non-compliance. We would uphold our initial
finding of non-compliance if the hospice could not show any
justification for non-compliance.
C. FY 2014 Hospice Wage Index and Rates Update
1. Hospice Wage Index
The hospice wage index is used to adjust payment rates for hospice
agencies under the Medicare program to reflect local differences in
area wage levels based on the location where services are furnished.
The hospice wage index utilizes the wage adjustment factors used by the
Secretary for purposes of section 1886(d)(3)(E) of the Act for hospital
wage adjustments and our regulations at Sec. 418.306(c) require each
labor market to be established using the most current hospital wage
data available, including any changes by the Office of Management and
Budget (OMB) to the Metropolitan Statistical Areas (MSAs) definitions.
We have consistently used the pre-floor, pre-reclassified hospital wage
index when deriving the hospice wage index. In our August 4, 2005 FY
2006 Hospice Wage Index final rule (70 FR 45130), we began adopting the
revised labor market area definitions as discussed in the OMB Bulletin
No. 03-04 (June 6, 2003). That bulletin announced revised definitions
for MSAs and the creation of Core-Based Statistical Areas (CBSAs). The
bulletin is available online at https://www.whitehouse.gov/omb/bulletins/b03-04.html. In the FY 2006 Hospice Wage Index final rule (70
FR 45139), we implemented a 1-year transition policy using a 50/50
blend of the CBSA-based wage index values and the MSA-based wage index
values for FY 2006. The one-year transition policy ended on September
30, 2006. For the FY 2007 hospice wage index and beyond, we have used
CBSAs exclusively to calculate wage index values. OMB has published
subsequent bulletins regarding CBSA changes. The OMB bulletins are
available at https://www.whitehouse.gov/omb/bulletins/.
When adopting OMB's new labor market designations in FY 2006, we
identified some geographic areas where there were no hospitals, and
thus, no hospital wage index data, which to base the calculation of the
hospice wage index. We also adopted the policy that, for urban labor
markets without a hospital from which hospital wage index data could be
derived, all of the CBSAs within the state would be used to calculate a
statewide urban average pre-floor, pre-reclassified hospital wage index
value to use as a reasonable proxy for these areas in our August 6,
2009 FY 2010 Hospice Wage Index final rule (74 FR 39386). In FY 2014,
the only CBSA without a hospital from which hospital wage data could be
derived is 25980, Hinesville-Fort Stewart, Georgia.
In our August 31, 2007 FY 2008 Hospice Wage Index final rule (72 FR
50214), we implemented a new methodology to update the hospice wage
index for rural areas without a hospital, and thus no hospital wage
data. In cases where there was a rural area without rural hospital wage
data, we used the average pre-floor, pre-reclassified hospital wage
index data from all contiguous CBSAs to represent a reasonable proxy
for the rural area. In our August 31, 2007 FY 2008 Hospice Wage Index
final rule, we noted that we interpret the term ``contiguous'' to mean
sharing a border (72 FR 50217). Currently, the only rural area without
a hospital from which hospital wage data could be derived is Puerto
Rico. However, our policy of imputing a rural pre-floor, pre-
reclassified hospital wage index based on the pre-floor, pre-
reclassified hospital wage index (or indices) of CBSAs contiguous to a
rural area without a hospital from which hospital wage data could be
derived does not recognize the unique circumstances of Puerto Rico.
While we have not identified an alternative methodology for imputing a
pre-floor, pre-reclassified hospital wage index for rural Puerto Rico,
we will continue to
[[Page 48268]]
evaluate the feasibility of using existing hospital wage data and,
possibly, wage data from other sources. For FY 2008 through FY 2013, we
have used the most recent pre-floor, pre-reclassified hospital wage
index available for Puerto Rico, which is 0.4047. In this final rule,
for FY 2014, we will continue to use the most recent pre-floor, pre-
reclassified hospital wage index value available for Puerto Rico, which
is 0.4047.
For the FY 2014 Hospice Wage Index and Payment Rate Update proposed
rule (78 FR 27840), we proposed to use the 2013 pre-floor, pre-
reclassified hospital wage index to derive the applicable wage index
values for the FY 2014 hospice wage index. We proposed to continue to
use the pre-floor, pre-reclassified hospital wage data as a basis to
determine the hospice wage index values because hospitals and hospices
both compete in the same labor markets, and therefore, experience
similar wage-related costs. We believe the use of the pre-floor, pre-
reclassified hospital wage index data as a basis for the hospice wage
index results in the appropriate adjustment to the labor portion of the
costs. The FY 2014 hospice wage index values presented in this final
rule were computed consistent with our pre-floor, pre-reclassified
hospital wage index policy (that is, our historical policy of not
taking into account Inpatient Prospective Payment System (IPPS)
geographic reclassifications in determining payments for hospice). The
2013 pre-floor, pre-reclassified hospital wage index does not reflect
OMB's new area delineations, based on the 2010 Census, as outlined in
OMB Bulletin 13-01, released on February 28, 2013. Moreover, the final
FY 2014 pre-floor, pre-reclassified hospital wage index does not
contain OMB's new area delineations because those changes were not
published until the IPPS proposed rule was in advanced stages of
development (78 FR 27552). CMS intends to propose changes to the FY
2015 hospital wage index based on the newest CBSA changes in the FY
2015 IPPS proposed rule. Therefore, if CMS incorporates OMB's new area
delineations, based on the 2010 Census, in the FY 2015 hospital wage
index, those changes would also be reflected in the FY 2016 hospice
wage index.
We received nine comments on our proposal to use the 2013 pre-
floor, pre-reclassified hospital wage index to derive the applicable
wage index values for the FY 2014 hospice wage index, which are
summarized below.
Comment: Some commenters commented that is difficult to have the
hospice wage index dependent on the hospital wage index due to the lack
of data sometimes submitted by the hospital on their cost report data
and the added responsibility for the hospice to monitor the hospital
wage index. Some commented that the phase out of the BNAF will leave
the hospice industry with an exceptionally imprecise and un-validated
wage index with large geographic variations that cannot be defended by
local wage pressures. Some commenters stated that CMS should actively
seek the Congressional authority for granting hospices wage index
parity with hospitals until an appropriate alternative wage index
approach for hospices and other post-acute providers can be developed.
One commenter asked CMS to re-evaluate the CBSA for Montgomery County,
Maryland as it is considered a rural area at paid at a lower rate than
all the surrounding counties.
Response: The pre-floor, pre-reclassified hospital wage index was
adopted in 1998 as the wage index from which the hospice wage index is
derived by a committee of CMS (then Health Care Financing
Administration) and industry representatives as part of a negotiated
rulemaking effort. The Negotiated Rulemaking Committee considered
several wage index options: (1) Continuing with Bureau of Labor
Statistics data; (2) using updated hospital wage data; (3) using
hospice specific data; and (4) using data from the physician payment
system. The Committee determined that the pre-floor, pre-reclassified
hospital wage index was the best option for hospice. Each hospice's
labor market area is based on definitions of CBSAs issued by the Office
of Management and Budget (OMB), not CMS. We note that section 3137(b)
of the Affordable Care Act requires CMS to submit to Congress a report
that includes a plan to reform the hospital wage index system. The
report to Congress outlines the recent history of analysis and proposed
reform to the Medicare wage index system. This report was submitted by
the Secretary on April 11, 2012. The report can be found at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Wage-Index-Reform.html. The latest information on
hospital wage index reform is discussed in the ``Hospital Inpatient
Prospective Payment Systems for Acute Care Hospitals and the Long-Term
Care Hospital Prospective Payment System and Fiscal Year 2013 Rates;''
final rule, published August 31, 2012 in the Federal Register (77 FR
53660-53664). We continue to believe that the pre-floor, pre-
reclassified hospital wage index, which is updated yearly and is used
by many other CMS payment systems, is the most appropriate method
available to account for geographic variances in labor costs for
hospices. Regarding about the commenters concerns regarding the CBSA
classification of Montgomery County, Maryland, it is important to note
that the cities and counties which make up CBSAs are not determined by
CMS, but instead are established by the Office of Management and Budget
(OMB) and have been adopted by Medicare through notice and comment rule
making. In our August 4, 2005 FY 2006 Hospice Wage Index final rule (70
FR 45130), we began adopting the revised labor market area definitions
as discussed in the OMB Bulletin No. 03-04 (June 6, 2003). In addition,
in the FY 2006 Hospice Wage Index final rule (70 FR 45130), we
implemented a 1-year transition policy using a 50/50 blend of the CBSA-
based wage index values and the MSA-based wage index values for FY
2006. The one-year transition policy ended on September 30, 2006. For
FY 2007 and beyond, we have used CBSAs exclusively to calculate wage
index values. Moreover, we also note that under the hospice payment
system, payments are wage-adjusted based on the location of the
beneficiary.
Final Decision: After carefully considering all of the comments
that we received on our proposal to use the 2013 pre-floor, pre-
reclassified hospital wage index to derive the applicable wage index
values for the FY 2014 hospice wage index, we are finalizing the
proposal as discussed in the FY 2014 Hospice Wage Index and Payment
Rate Update proposed rule.
2. FY 2014 Hospice Wage Index With an Additional 15 Percent Reduced
Budget Neutrality Adjustment Factor (BNAF)
This final rule will update the hospice wage index values for FY
2014 using 2013 pre-floor, pre-reclassified hospital wage index. As
described in the August 8, 1997 Hospice Wage Index final rule (62 FR
42860), the pre-floor and pre-reclassified hospital wage index is used
as the raw wage index for the hospice benefit. These raw wage index
values are then subject to either a budget neutrality adjustment or
application of the hospice floor to compute the hospice wage index used
to determine payments to hospices. Pre-floor, pre-reclassified hospital
wage index values below 0.8 are adjusted by either: (1) The hospice
budget neutrality adjustment factor (BNAF); or (2) the hospice floor
subject to a maximum wage index value of 0.8; whichever results in the
greater value.
[[Page 48269]]
The BNAF is calculated by computing estimated payments using the
most recent, completed year of hospice claims data. The units (days or
hours) from those claims are multiplied by the updated hospice payment
rates to calculate estimated payments. For the FY 2014 Hospice Wage
Index final rule, that means estimating payments for FY 2014 using
units (days or hours) from FY 2012 hospice claims data, and applying
the FY 2014 hospice payment rates. The FY 2014 hospice wage index
values are then applied to the labor portion of the payments. The
procedure is repeated using the same units from the claims data and the
same payment rates, but using the 1983 Bureau of Labor Statistics
(BLS)-based wage index instead of the updated raw pre-floor, pre-
reclassified hospital wage index (note that both wage indices include
their respective floor adjustments). The total payments are then
compared, and the adjustment required to make total payments equal is
computed; that adjustment factor is the BNAF.
The August 6, 2009 FY 2010 Hospice Wage Index final rule (74 FR
39384) finalized a provision to phase out the BNAF over 7 years, with a
10 percent reduction in the BNAF in FY 2010, and an additional 15
percent reduction in each of the next 6 years, with complete phase out
in FY 2016. Once the BNAF is completely phased out, the hospice floor
adjustment would simply consist of increasing any wage index value less
than 0.8 by 15 percent, subject to a maximum wage index value of 0.8.
Therefore, in accordance with the FY 2010 Hospice Wage final rule (74
FR 39384), the BNAF for FY 2014 will be reduced by an additional 15
percent for a total BNAF reduction of 70 percent (10 percent from FY
2010, an additional 15 percent from FY 2011, an additional 15 percent
for FY 2012, an additional 15 percent for FY 2013 and an additional 15
percent in FY 2014).
The unreduced BNAF for FY 2014 is 0.061538 (or 6.1538 percent). A
70 percent reduction to the BNAF is computed to be 0.018461 (or 1.8461
percent). For FY 2014, this is mathematically equivalent to taking 30
percent of the unreduced BNAF value, or multiplying 0.061538 by 0.30,
which equals 0.018461 (1.8461 percent). The BNAF of 1.8461 percent
reflects a 70 percent reduction in the BNAF. The 70 percent reduced
BNAF (1.8461 percent) was applied to the pre-floor, pre-reclassified
hospital wage index values of 0.8 or greater. The 10 percent reduced
BNAF for FY 2010 was 0.055598, based on a full BNAF of 0.061775; the
additional 15 percent reduced BNAF FY 2011 (for a cumulative reduction
of 25 percent) was 0.045422, based on a full BNAF of 0.060562; the
additional 15 percent reduced BNAF for FY 2012 (for a cumulative
reduction of 40 percent) was 0.035156, based on a full BNAF of
0.058593; the additional 15 percent reduced BNAF for FY 2013 (for a
cumulative reduction of 55 percent) was 0.027197, based on a full BNAF
of 0.060438; and the additional 15 percent reduced BNAF for FY 2014
(for a cumulative reduction of 70 percent) is 0.018461, based on a full
BNAF of 0.061538.
Hospital wage index values which are less than 0.8 are subject to
the hospice floor calculation. For example, if in FY 2013, County A had
a pre-floor, pre-reclassified hospital wage index (raw wage index)
value of 0.3994, we would perform the following calculations using the
budget-neutrality factor (which for this example is an unreduced BNAF
of 0.061538, less 70 percent, or 0.018461) and the hospice floor to
determine County A's hospice wage index: Pre-floor, pre-reclassified
hospital wage index value below 0.8 multiplied by 1+ 70 percent reduced
BNAF: (0.3994 x 1.018461 = 0.4068); Pre-floor, pre-reclassified
hospital wage index value below 0.8 multiplied by 1 + hospice floor:
(0.3994 x 1.15 = 0.4593). Based on these calculations, County A's
hospice wage index would be 0.4593.
An Addendum A and Addendum B, with the FY 2014 wage index values
for rural and urban areas, will not be published in the Federal
Register. The FY 2014 wage index values for rural areas and urban areas
are available via the internet at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/. The FY 2014
hospice wage index set forth in this final rule includes the BNAF
reduction and will be effective October 1, 2013 through September 30,
2014.
We received nine comments which referenced the BNAF reduction, and
are summarized below.
Comment: Several commenters continued to voice opposition to the
BNAF reduction and were concerned about the impact of the elimination
of BNAF phase-out.
Response: The BNAF phase-out has already been finalized for the
remaining years of the phase-out, as described in the FY 2010 Hospice
Wage Index final rule (74 FR 39384). However, we are sensitive to the
issues raised by commenters, especially the possible effects of the
BNAF reduction. Our analysis reveals an overall growth in number of
hospices since the start of the phase-out. We also note that the FY
2014 hospice wage index includes a hospice floor calculation which
benefits many rural providers. However, we will continue to monitor for
unintended consequences associated with the BNAF phase-out.
3. Hospice Payment Update Percentage
Section 4441(a) of the Balanced Budget Act of 1997 (BBA) amended
section 1814(i)(1)(C)(ii)(VI) of the Act to establish updates to
hospice rates for FYs 1998 through 2002. Hospice rates were to be
updated by a factor equal to the market basket index, minus 1
percentage point. Payment rates for FYs since 2002 have been updated
according to section 1814(i)(1)(C)(ii)(VII) of the Act, which states
that the update to the payment rates for subsequent FYs must be the
market basket percentage for that FY. The Act requires us to use the
inpatient hospital market basket to determine the hospice payment rate
update. In addition, section 3401(g) of the Affordable Care Act
mandates that, starting with FY 2013 (and in subsequent FYs), the
hospice payment update percentage will be annually reduced by changes
in economy-wide productivity as specified in section
1886(b)(3)(B)(xi)(II) of the Act which is 0.5 percentage point for FY
2014. In addition, section 3401(g) of the Affordable Care Act also
mandates that in FY 2013 through FY 2019, the hospice payment update
percentage will be reduced by an additional 0.3 percentage point
(although for FY 2014 to FY 2019, the potential 0.3 percentage point
reduction is subject to suspension under conditions specified in
section 1814(i)(1)(C)(v) of the Act). In FY 2014 Hospice Wage Index and
Payment Rate Update proposed rule (78 FR 27841), we proposed 1.8
percent hospice payment update percentage which was based on a 2.5
percent estimated inpatient hospital market basket update for FY 2014
reduced by a 0.4 percentage point productivity adjustment and by 0.3
percentage point as mandated by the Affordable Care Act. The final
hospice payment update percentage for FY 2014 is 1.7 percent and is
based on the final inpatient hospital market basket update for FY 2014
of 2.5 percent reduced by a 0.5 percentage point productivity
adjustment and by 0.3 percentage point as mandated by the Affordable
Care Act. A detailed description of how the inpatient hospital market
basket is derived is described in the FY 2014 IPPS Final Rule. Due to
the requirements at 1886(b)(3)(B)(xi)(II) and 1814(i)(1)(C)(v) of the
Act, the inpatient hospital market basket update for FY 2014 of 2.5
percent must be reduced by a productivity adjustment as mandated by
Affordable Care Act (0.5 percentage point for FY 2014). The inpatient
[[Page 48270]]
hospital market basket for FY 2014 is reduced further by a 0.3
percentage point, as mandated by the Affordable Care Act. In effect,
the final hospice payment update percentage for FY 2014 is 1.7 percent.
The labor portion of the hospice payment rates are as follows: for
Routine Home Care, 68.71 percent; for Continuous Home Care, 68.71
percent; for General Inpatient Care, 64.01 percent; and for Respite
Care, 54.13 percent. The non-labor portion of the payment rates is as
follows: for Routine Home Care, 31.29 percent; for Continuous Home
Care, 31.29 percent; for General Inpatient Care, 35.99 percent; and for
Respite Care, 45.87 percent.
4. Final FY 2014 Hospice Payment Rates
Historically, the hospice rate update has been published through a
separate administrative instruction issued annually in the summer to
provide adequate time to implement system change requirements; however,
starting in this FY 2014 rule and for subsequent FYs, we proposed in
the FY 2014 Hospice Wage Index and Payment Rate Update proposed rule to
use rulemaking as the means to finalize hospice payment rates. This
change was proposed to be consistent with the rate update process in
other Medicare benefits, and would provide rate information to hospices
as quickly as, or earlier than, when rates are published in an
administrative instruction.
There are four payment categories that are distinguished by the
location and intensity of the services provided. The base payments are
adjusted for geographic differences in wages by multiplying the labor
share, which varies by category, of each base rate by the applicable
hospice wage index. A hospice is paid the routine home care rate for
each day the beneficiary is enrolled in hospice, unless the hospice
provides continuous home care, inpatient respite care, or general
inpatient care. Continuous home care is provided during a period of
patient crisis to maintain the patient at home, inpatient respite care
is short-term care to allow the usual caregiver to rest, and general
inpatient care is to treat symptoms that cannot be managed in another
setting.
The final FY 2014 payment rates will be the FY 2013 payment rates,
increased by 1.7 percent, which is the final hospice payment update
percentage for FY 2014 as discussed in section IV.C.3 above. The final
FY 2014 hospice payment rates will be effective for care and services
furnished on or after October 1, 2013, through September 30, 2014.
Table 7--Final FY 2014 Hospice Payment Rates Updated by the Final Hospice Payment Update Percentage
----------------------------------------------------------------------------------------------------------------
Multiply by
the FY 2014
Code Description FY 2013 final hospice FY 2014 final
Payment rates payment update payment rate
of 1.7 percent
----------------------------------------------------------------------------------------------------------------
651...................... Routine Home Care.................... $153.45 x 1.017 $156.06
652...................... Continuous Home Care Full Rate = 24 895.56 x 1.017 910.78
hours of care = 37.95 hourly rate.
655...................... Inpatient Respite Care............... 158.72 x 1.017 161.42
656...................... General Inpatient Care............... 682.59 x 1.017 694.19
----------------------------------------------------------------------------------------------------------------
The Congress required in sections 1814(i)(5)(A) through (C) of the
Act that hospices begin submitting quality data, based on measures to
be specified by the Secretary. Beginning in FY 2014, hospices which
fail to report quality data will have their market basket update
reduced by 2 percentage points. In the August 4, 2011 FY 2012 Hospice
Wage Index final rule (76 FR 47320 through 47324), we implemented a
Hospice Quality Reporting Program (HQRP) as required by section 3004 of
the Affordable Care Act. Hospices were required to begin collecting
quality data in October 2012, and submit that quality data in 2013.
Hospices failing to report quality data in 2013 will have their market
basket update reduced by 2 percentage points in FY 2014.
Table 8--Final FY 2014 Hospice Payment Rates Updated by the Final Hospice Payment Update Percentage for Hospices
That Do Not Submit the Required Quality Data
----------------------------------------------------------------------------------------------------------------
Multiply by
the FY 2014
hospice
payment update
Code Description FY 2013 percentage of FY 2014
Payment rates 1.7 percent Payment rate
minus 2
percentage
points (-0.2)
----------------------------------------------------------------------------------------------------------------
651................................ Routine Home care.......... $153.45 x 0.997 $152.99
652................................ Continuous Home Care Full 895.56 x 0.997 892.87
Rate = 24 hours of care =
37.20 hourly rate.
655................................ Inpatient Respite Care..... 158.72 x 0.997 158.24
656................................ General Inpatient Care..... 682.59 x 0.997 680.54
----------------------------------------------------------------------------------------------------------------
A Change Request with the finalized FY 2014 hospice payment rates,
a finalized FY 2014 hospice wage index, the FY 2014 PRICER, and the
hospice cap amount for the cap year ending October 31, 2013 will
continue to be issued in the summer.
We received two comments on our proposal to use rulemaking as the
means to finalize hospice payment rates, which are summarized below.
Comment: Commenters were supportive of CMS' proposal to use
rulemaking as the means to finalize hospice payment rates followed by a
change request with the finalized hospice payment rates, a finalized
[[Page 48271]]
hospice wage index, the PRICER for FY 2014.
Response: We thank you for your support. We will finalize hospice
payment rates as stated in the FY 2014 Hospice Wage Index and Payment
Rate Update proposed rule (78 FR 27841).
Comment: We also received several additional comments that
expressed concern that hospice industry is being over regulated, while
reimbursement is decreasing and examples given include the face-to-face
regulation, data collection efforts, and quality initiatives. Several
commenters are concerned that these regulations not only increase
financial burden for hospice industry but also pull hospices away from
patient care and keep hospice providers in the office to perform
administrative duty to comply with regulations. Some commenters
described a shortage of staff in some areas of the country, especially
small hospices and in rural areas, and stated that the staff travel
hours in rural areas to examine the patient, which is a burden itself
because of travel distance. Several commenters stated that
reimbursement is decreasing because of the continuing rate cuts
resulting from the elimination of the budget neutrality adjustment
factor, the cuts resulting from the productivity adjustment factor, and
further rate reduction resulting from sequestration. A commenter stated
that the proposed hospice payment update of 1.8 percent for 2014,
coupled with other cuts is devastating.
Response: We appreciate comments regarding sequestration cut, but
it is outside the scope of this rule. As stated in FY 2013 Hospice Wage
Index notice (77 FR 44245), section 3401(g) of the Affordable Care Act
mandates that starting with FY 2013 (and in subsequent FYs), the market
basket percentage update under the hospice payment system as described
in section 1814(i)(1)(C)(ii)(VII) or section 1814(i)(1)(C)(iii) of the
Act will be annually reduced by changes in economy-wide productivity as
set out at section 1886(b)(3)(B)(xi)(II) of the Act. We do not have
authority to change the application of economy-wide productivity
adjustment as it is required by the statute. We are sensitive to
concerns about hospices being overregulated and concerns expressed from
rural hospices that the additional time and distance required to visit
a rural patient adds significantly to their costs. We do not have the
authority to change the hospice rates beyond the limits set out in the
statute, but will consider the costs of rural providers in the context
of broader hospice payment system reform. We will continue to monitor
the impact of our regulations for any unintended consequences. As
described in the Regulatory Impact Analysis (Section, VI), we note that
the overall impact of this final rule is an estimated net increase in
Federal payments to hospices of $160 million, or 1.0 percent, for FY
2014.
Final Decision: As stated in the FY 2014 Hospice Wage Index and
Payment Rate Update proposed rule, we proposed to finalize hospice
payment rates through rulemaking and we are finalizing this policy as
proposed. A change request with the finalized FY 2014 hospice payment
rates, a finalized FY 2014 hospice wage index, the FY 2014 PRICER, and
the hospice cap year ending October 31, 2013 will continue to be issued
in the summer.
D. Update on Hospice Payment Reform and Data Collection
In 2010, the Congress amended section 1814(i)(6) of the Act with
section 3132(a) of the Affordable Care Act. The amendment authorized
the Secretary to collect additional data and information determined
appropriate to revise payments for hospice care and for other purposes.
The types of data and information described in the Act would capture
resource utilization and other measures of cost, which can be collected
on claims, cost reports, and possibly other mechanisms determined to be
appropriate. The data collected may be used to revise the methodology
for determining the payment rates for routine home care, and other
services included in hospice care, no earlier than October 1, 2013 as
described in section 1814(i)(6)(D) of the Act. In addition, we are
required to consult with hospice programs and the Medicare Payment
Advisory Commission (MedPAC) regarding additional data collection and
payment revision options.
The proposed rule contained three subsections which updated the
public or discussed different aspects of hospice payment reform; there
were no proposals in any of these three subsections.
1. Update on Reform Options
Our hospice contractor, Abt Associates, continues to conduct
research and analyses, to identify potential data collection needs, and
to research and develop hospice payment model options. To date, we
completed an environmental scan; a draft analytic plan; and convened
technical advisory panel meetings under the initial contract with Abt
in 2010. We are continuing with these efforts under a contract awarded
in September 2011. In June 2012, we convened stakeholder meetings where
research findings were presented on potential payment system
vulnerabilities; utilization of the Medicare Hospice Benefit, including
general inpatient care use during the period the beneficiary is
enrolled in hospice care; analysis of hospice cost reports; and the
effects of the face-to-face encounter requirement. These and other
findings are described in the Abt Hospice Study Technical Report, which
is available on the CMS Hospice Center Web page, at https://www.cms.gov/Center/Provider-Type/Hospice-Center.html.
Additionally, we continue to conduct analyses of various payment
reform model options under consideration. These models include a U-
shaped model of resource use, which MedPAC recommended that we adopt,
as originally described in Chapter 6 of its March, 2009 report entitled
``Report to the Congress: Medicare Payment Policy'' (available online
at: https://www.medpac.gov/chapters/Mar09_Ch06.pdf). The report noted
that the constancy of the per diem payment over the course of a hospice
stay is misaligned with a hospice's costs during the stay. A hospice's
costs typically follow a U-shaped curve, with higher costs at the
beginning and end of a stay, and lower costs in the middle of the stay.
This cost curve reflects hospices' higher service intensity at the time
of the patient's admission and the time surrounding the patient's death
(MedPAC, page 358). Payment under a U-shaped model would be higher at
the beginning and end of a hospice stay and lower in the middle portion
of the stay.
Analysis conducted by Abt Associates found that very short hospice
stays have a flatter curve than the U-shaped curve seen for longer
stays and that average hospice costs are much higher. These short stays
are less U-shaped because there is not a lower-cost middle period
between the time of admission and the time of death. As such, we are
also considering a tiered approach, with payment tiers based on the
length of stay. For example, payment for stays of 5 days or less, which
occurred for about 25 percent of hospice beneficiaries in 2011, could
be made under a per diem system that accounts for the higher hospice
costs, with no variation in the rate based on length of stay as would
occur under a U-shaped model. Payment for longer stays, where costs
follow more of a U-shape, could be made under a tier based on the U-
shaped payment model, where the per diem amount fluctuates depending
upon whether the days billed are at the beginning, middle, or end of
the stay.
[[Page 48272]]
Another option is to analyze whether a short-stay add-on payment,
similar to the home health Low Utilization Payment Amount (LUPA) add-
on, would improve payment accuracy if we retain the current per diem
system. The LUPA add-on is made for home health patients who require
four or fewer visits during the 60-day episode. These home health
episodes are paid based on the visits actually furnished during the
episode. For LUPA episodes that occur as the only episode or the first
episode in a sequence of adjacent home health episodes for a given
beneficiary, an increased payment is made to account for the front-
loading of costs (see https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/HomeHlthProspaymt.pdf for more information).
Finally, as we collect more accurate diagnosis data, including data
on related conditions, we will also evaluate whether case-mix should
play a role in determining payments.
a. Rebasing the Routine Home Care (RHC) Rate
In the proposed rule, we updated our review of the hospice RHC
rate, but did not include any proposals to rebase the rate. Rebasing
the RHC rate involves using the existing components that make up the
rate, and recalculating based on more current data. RHC is the basic
level of care under the Hospice benefit, where a beneficiary receives
hospice care, but remains at home. With this level of care, hospice
providers are reimbursed per day regardless of the volume or intensity
of services provided to a beneficiary on any given day. It is
anticipated that there would be days when a beneficiary does not
require any services, as well as days when a beneficiary requires
several visits from the hospice provider.
When the hospice benefit was created in 1983, the RHC base payment
rate was set using nine different components of cost from a relatively
small set of hospices (n = 26) that were participating in a CMS hospice
demonstration, as described in the December 16, 1983 Hospice final rule
(48 FR 56008). The nine cost components were: nursing care ($16.25);
home health aide ($12.74); social services/therapy ($3.23); home
respite ($1.46); interdisciplinary group ($2.78); drugs ($1.18);
supplies ($4.49); equipment ($1.13); and outpatient hospital therapies
($2.99). The sum of all the components' costs equaled the base payment
rate for RHC as stated in that 1983 hospice final rule. The original
RHC rate was set at $46.25. In addition to RHC, we also established
three other levels of care for hospice care from data obtained from the
Medicare hospice demonstration project: Continuous Home Care (CHC),
Inpatient Respite Care (IRC) and General Inpatient Care (GIP).
It is CMS' intent to ensure that reimbursement rates under the
Hospice benefit align as closely as possible with the average costs
hospices incur when efficiently providing covered services to
beneficiaries. As we continue to gather and analyze more data for
payment reform, we have found evidence of a potential misalignment
between the current RHC payment rate and the cost of providing RHC. One
potential option to address this misalignment could be to rebase the
hospice RHC rate, though we did not propose to do so in the proposed
rule, so that the cost categories established in the rate reflect the
changes in the utilization of hospice services provided for palliation
and management of terminally ill patients. However, we are still
evaluating data and did not propose any changes to address the
misalignment.
At this time, we do not have the data to support rebasing six of
the nine cost components described in the 1983 final rule. Information
on the utilization of drugs, supplies, and equipment is not available
from hospice claims data, and the corresponding information that is
available from cost reports, such as outpatient hospital therapies, is
not sufficiently detailed to allow for rebasing. One approach to
consider in more closely aligning RHC payments with costs is to rebase
the three clinical service components (nursing, home health aide,
social services/therapy) that currently comprise 69.7 percent of the
RHC rate by calculating the average cost per day, weighted by the
number of RHC days, for each of the three components using FY 2011 cost
report data matched to FY 2011 claims data. As part of rebasing the RHC
rate we would then inflate the 1983 cost per day for each of the six
remaining components by a factor of 3.1704, which corresponds to the
market basket increases between 1983 and 2011.\8\ We note that our cost
report analysis thus far found that drug costs over the years have
declined, and the other non-labor components are plateauing. A detailed
methodology for rebasing the clinical service components of the RHC
rate can be found in the Abt Hospice Study Technical Report which was
published shortly after displaying the proposed rule, at https://www.cms.gov/Center/Provider-Type/Hospice-Center.html.
---------------------------------------------------------------------------
\8\ The original RHC rate in 1983 was $46.25. The FY 2011 rate
for RHC was $146.63. $146.63/46.25 = 3.1704.
---------------------------------------------------------------------------
Using the methodology described above, the rebased amount for FY
2011 would be $130.54 as described in Table 9 below.
Table 9--Comparison of RHC Rate Cost Components From 1983 to FY 2011
------------------------------------------------------------------------
1983 Final FY 2011
RHC components rule cost Inflation Cost per
per day factor day
------------------------------------------------------------------------
Nursing Care..................... $16.25 N/A $56.54
Home Health Aide................. 12.74 N/A 19.24
Social Services/Therapy.......... 3.23 N/A 10.29
Home respite..................... 1.46 x 3.1704 4.63
Interdisciplinary group.......... 2.78 x 3.1704 8.81
Drugs............................ 1.18 x 3.1704 3.74
Supplies......................... 4.49 x 3.1704 14.23
Equipment........................ 1.13 x 3.1704 3.58
Outpatient Hospital Therapies.... 2.99 x 3.1704 9.48
Total........................ 46.25 ........... 130.54
------------------------------------------------------------------------
Source: 1983 Final Rule and FY 2011 hospice cost report and claims data.
[[Page 48273]]
Note(s): The costs per day for the clinical services components (nursing
care, home health aide and social services/therapy) were calculated
based on the cost per minute for each discipline using cost report
data multiplied by the RHC minutes for each discipline per RHC day
from claims data to compute the cost of a discipline per RHC day. The
average cost per day across all hospices in our sample was weighted by
the number of RHC days. Of the 2,717 FY 2011 hospice cost reports for
freestanding and facility-based hospices that were matched to FY 2011
claims data, we excluded: (1) Cost reports with period less than 10
months or greater than 14 months; (2) cost reports with missing
information or negative reported values for total costs or payments;
(3) providers in the highest and lowest percentile (1% and 99%) in
costs per days across all levels of care; (4) the top and bottom 5% of
provider margin; and (5) providers were excluded if the log payment to
cost ratio was greater than the 90th or less than the 10th percentile
of this value across all providers plus or minus 1.5 times the range
between the 10th and 90th percentiles of this log ratio. The number of
hospices remaining in our sample was 2,140 representing 73.1 percent
of RHC days in 2011.
For example, if we were to apply the rebased amounts for the
clinical services components of RHC to FY 2014, we would inflate the FY
2011 rebased amount to FY 2013 levels. We first inflated the FY 2011
rebased rate by full hospital market basket of 3.0 percent for FY 2012.
The FY 2012 rebased rate would be $134.46 ($130.54 x 1.03 = $134.46).
We then inflated the FY 2012 rebased rate by full hospital market
basket of 2.6 percent for FY 2013. The FY 2013 rebased rate would be
$137.96 ($134.46 x 1.026 = $137.96). Finally, we inflated the rebased
FY 2013 rate ($137.96) by applying the proposed hospice payment update
percentage of 1.8 percent to calculate a FY 2014 rebased RHC rate.
Therefore, the FY 2014 rebased rate would be $140.44, a 10.1 percent
reduction in the FY 2014 proposed RHC payment rate of $156.21, or an
estimated reduction in payments to hospices of $1.6 billion in FY 2014.
Rebasing the clinical service components of the RHC payment is one of
several approaches to hospice payment reform that CMS could consider
for revising the RHC payment rate. As outlined in the Affordable Care
Act, hospice payment reform must be done in a budget neutral manner. As
rebasing is considered part of hospice payment reform, any savings
achieved through the reduction of the RHC rate would need to be
redistributed in a budget neutral manner.
b. Site of Service Adjustment for Hospice Patients in Nursing
Facilities.
As part of future hospice payment reform, we are considering an OIG
recommendation to reduce payments to Medicare hospices for
beneficiaries in nursing facilities who are receiving hospice care. The
OIG's July 2011 report entitled ``Medicare Hospices that Focus on
Nursing Facility Residents,'' (available at https://oig.hhs.gov/oei/reports/oei-02-10-00070.pdf) studied hospice patients in nursing
facilities. This report noted the growth of hospice services provided
to beneficiaries in nursing facilities, and discussed hospices that
have a high percentage of their beneficiaries in nursing facilities.
The OIG's report noted that the current payment structure provides
incentives for hospices to seek out beneficiaries in nursing
facilities, as these beneficiaries often receive longer but less
complex care. The OIG noted that unlike private homes, nursing
facilities are staffed with professional caregivers and are often paid
by third-party payers, such as Medicaid. These facilities are required
to provide personal care services, which are similar to hospice aide
services that are paid for under the hospice benefit. To lessen this
incentive, the OIG recommended that we reduce Medicare payments for
hospice care provided in nursing facilities.
In addition, the March 2012 Medicare Payment Advisory Commission
(MedPAC) report entitled ``Report to Congress: Medicare Payment
Policy'' noted that hospices with a higher share of their patients in
nursing facilities have margins as high as 13.8 percent (pages 302 and
303). MedPAC attributed these higher margins to possible efficiencies
in the nursing home setting (multiple patients in a single setting,
reduced driving time and mileage), and to reduced workload due to an
overlap in aide services and supplies provided by the nursing facility.
In response to both MedPAC's and OIG's concerns about possible
duplication of aide services provided both by the hospice and the
nursing facility, in the proposed rule we discussed an analysis of the
number and length of aide visits per day using 2011 hospice claims
data. Table 10 below describes the number and length of aide visits for
RHC beneficiaries at home (including patients in an assisted living
facility) compared to RHC beneficiaries in a long term care nursing
facility (NF) or skilled nursing facility (SNF).
Table 10--Hospice Routine Home Care Aide Services, CY 2011
----------------------------------------------------------------------------------------------------------------
Sites of service Difference
-----------------------------------------------------------------------
Home Q5001/2 NF/SNF Q5003/4 NF/SNR-Home %
----------------------------------------------------------------------------------------------------------------
Number of beneficiaries................. 769,640 302,004 (467,636) ................
Total days.............................. 58,637,171 22,946,972 (35,690,199) ................
Total visits............................ 16,625,635 8,501,366 (8,124,269) ................
Total minutes........................... 1,223,254,095 584,825,520 (638,428,575) ................
Visits per beneficiary.................. 21.6 28.1 6.5 30.3
Minutes per visit....................... 73.6 68.8 (4.8) 6.5
Total visits/day........................ 0.28 0.37 0.09 30.7
Total minutes/day....................... 20.86 25.49 4.62 22.2
----------------------------------------------------------------------------------------------------------------
Source: Abt Associates Hospice Claims Data File, CY 2011.
Table 10 demonstrates that hospice patients in a NF/SNF receive
more visits than patients at home, though the length of those visits is
shorter. Average minutes per day shows that RHC patients in a NF/SNF
had hospice aide services of longer duration (25.49 minutes) than RHC
patients at home (20.86 minutes). The Medicare Conditions of
Participation (CoPs) require that hospices provide services at the same
level and to the same extent as those services would be provided if the
NF/SNF resident were in his or her home. Hospices provide aide services
to beneficiaries at home depending on the beneficiaries' needs. It
seems reasonable to expect that a beneficiary who has a paid caregiver
(that is, a NF/SNF aide) does not need as many services from the
hospice aide, because those services are being provided by the paid
caregiver. As described in the June 5, 2008 Hospice Conditions of
Participation final rule (73
[[Page 48274]]
FR 32095), ``[h]ospice care is meant to supplement the care provided by
the patient's caregiver.'' Given the presence of the paid caregiver in
the NF/SNF, we would expect that on average, there would be fewer
hospice aide services provided to hospice patients in a NF/SNF than to
hospice patients at home.
It is not clear why hospice patients in nursing facilities are
receiving more minutes per day of aide services than hospice patients
at home. We used regression analysis to control for age, gender,
diagnosis, length of stay, and provider characteristics (ownership
status, base, size, age of hospice, geographic location) when analyzing
the visit data. However, we still found that significantly more aide
services were provided to NF/SNF patients than to patients at home,
even after controlling for patient and provider characteristics.
The June 5, 2008 Hospice Conditions of Participation final rule (73
FR 32088) preamble details the requirements related to aide services
provided to hospice patients residing in a nursing facility. These
requirements can also be found at Sec. 418.112(c)(4) through (5). The
CoPs require a written agreement between the hospice and NF/SNF, which
specifies that the NF/SNF should continue to provide the aide services
that are provided prior to the hospice election, to meet the patient's
needs at that same level of care as if the patient were at home. These
services include providing 24 hour room and board care, meeting the
patient's personal care needs, and to the degree permitted by State
law, administering medications or therapies. There should be no
reduction of NF/SNF aide services to a patient in anticipation of a
future hospice election, or once the patient (or his/her
representative) elects the hospice benefit. As such, hospice patients
in nursing facilities should have much, if not most, of their need for
aide services provided by the facility's aide. As stated previously, we
would expect that, on average, the hospice aide would be providing
fewer services to nursing facility patients than to patients at home.
Table 10 suggests that the hospice aide may be replacing the
facility aide, rather than supplementing or augmenting the care of the
facility aide. Or, as the OIG and MedPAC identified, there could be an
overlap in aide services when a hospice beneficiary is in a NF/SNF. It
would not be appropriate for the Medicare Hospice Benefit to subsidize
the nursing home benefit by providing aide services that the facility
aide should provide. Section 1862(a)(1)(C) of the Social Security Act
(the Act) forbids payment for any items or services which are not
reasonable and necessary for the palliation and management of the
terminal illness. Services which are not needed, or which are
duplicative of those to be provided by the facility aide, would not be
reasonable and necessary.
In the proposed rule, we did not propose to make a site of service
adjustment to reduce payments for RHC patients in a nursing facility.
Any reform option considering reduced payments for RHC care provided to
hospice patients in a NF or SNF should not result in a reduction in the
services that hospice patients in NFs or SNFs receive, but would
instead be a shifting of who provides those aide services; some of the
services currently provided by the hospice aide would be provided by
the facility aide as expected. As such, we do not expect that the
quality of care to hospice patients in a NF/SNF would be diminished. If
such a policy were to be finalized and implemented, it would be made in
a budget neutral manner as required by the Affordable Care Act. In
addition, we would monitor for any unintended consequences.
2. Reform Research Findings
The proposed rule also included a discussion of a number of
analyses we conducted to better understand hospice utilization and
trends, to identify vulnerabilities in the payment system, and to
develop and test models that would more accurately match hospice
resource use with Medicare payments. We posted the Abt Hospice Study
Technical Report on hospice payment reform on our hospice center Web
page, located at: https://www.cms.gov/Center/Provider-Type/Hospice-Center.html. The report summarizes research findings related to
resource use and payment system vulnerabilities.
The report also includes a discussion of hospice cost report
analyses. Overall, the total cost per election period has not
significantly increased from 2007 to 2010, in real dollars. Inpatient
costs constitute about 14 percent of hospice costs across freestanding
hospice providers that reported inpatient costs. About one-third of
providers reported no inpatient costs. It appeared that some providers
with no inpatient costs were substituting continuous home care (CHC)
for GIP, based on analysis of the proportion of CHC days. Visiting
services (for example, direct labor costs for nurses, aides, social
workers, counselors, and therapists) account for about two-thirds of
hospice costs, and have trended upward from 2004 to 2010. Nursing care,
hospice aides, and medical social services comprise 90 percent of
visiting service costs.
Other hospice service costs include non-labor costs such as drugs,
durable medical equipment (DME), supplies, imaging, patient
transportation, and outpatient services. These types of services
represent about 20 to 25 percent of total hospice costs. Drugs, DME,
and supplies account for 90 percent of these other hospice services
costs. Drug costs have trended downward over time, while medical supply
costs have remained steady. Finally, in examining non-reimbursable
costs, we found that 26 percent of providers in 2010 showed no
bereavement costs on their cost report, even though bereavement
services are required by statute; it is unclear if bereavement services
were not provided or if bereavement costs were not correctly reported.
The report also describes an analysis of GIP utilization. In 2010
through 2011, a quarter of all hospice beneficiaries had at least one
GIP stay, with a quarter of those stays associated with cancer
diagnoses. While most GIP stays were 2 days long, the average GIP
length of stay was 5.66 days, reflecting a small number of extremely
long GIP stays. Sixty-five percent of GIP stays were provided in a
hospice inpatient unit. Almost 80 percent of hospices provided at least
one GIP day in 2010 through 2011. Hospices that provided GIP tended to
be older and larger.
The Abt Hospice Study Technical Report also provides descriptive
statistics for all beneficiaries and for 3 major sites of routine home
care services. It includes visit data findings, including visits per
day, visits per beneficiary, minutes per day, and minutes per
beneficiary for key disciplines reported on hospice claims.
Additionally, there are several figures which depict the U-shaped curve
for key personnel by length of stay. The curves show that resource use
tends to follow a U-shaped curve, but one which is higher at the
beginning rather than at the end of the hospice stay. There was little
evidence that strong differences in the U-shape exist across most
subgroups (for example, freestanding vs. provider-based, ownership
status, patient diagnosis).
For more detailed information on these findings, and a description
of the methods used, see the Abt Hospice Study Technical Report, which
is posted on the hospice center Web page (https://www.cms.gov/Center/Provider-Type/Hospice-Center.html). We have also posted a review of
pertinent hospice literature as of December 2012 on the hospice center
Web page. This should be considered an evolving document, as Abt
Associates updates
[[Page 48275]]
the review periodically. We encourage interested stakeholders to review
this update on our progress. We will continue to collaborate with other
federal experts regarding hospice payment reform research efforts and
to update stakeholders on our progress on hospice payment reform.
3. Additional Data Collection
Over the past several years, MedPAC, the Government Accountability
Office (GAO), and the HHS Office of Inspector General (OIG) have also
recommended that we collect more comprehensive data in order to better
understand the utilization of the Medicare Hospice Benefit. In the
proposed rule, we noted that in December 2012 we posted a document to
our Hospice Center Web page (https://www.cms.gov/Center/Provider-Type/Hospice-Center.html) describing additional data collection which we are
considering, and noting that cost report revisions are forthcoming. We
received 65 comments about the claims data collection items under
consideration, which are briefly summarized below.
Line item visit data, including length of visit in 15-
minute increments, for hospice chaplains and counselors providing care
to hospice beneficiaries. Commenters were supportive, but suggested we
include phone calls by chaplains and counselors, and allow reporting of
chaplain time spent officiating or attending beneficiary funerals, as
this is part of their service to families. A few suggested that we have
a separate category for Bereavement Counseling to acknowledge this
requirement even if it is not subject to reimbursement. Several
suggested we define ``other counselors.''
Line item visit data, including length of visits in 15-
minute increments, for hospice staff providing care to hospice patients
receiving GIP in a hospital or nursing facility, but not for hospice
patients receiving GIP in a hospice facility. Our suggestion to collect
GIP visit data did not include visits by non-hospice staff, and was
focused on patients in a hospital or nursing facility only. Therefore,
GIP visits to hospice patients in hospice inpatient facilities continue
to be reported as weekly totals, without including the length of
visits. Commenters were generally supportive, provided the visits were
for hospice staff only. Several comments noted that this would be no
more difficult than what already occurs when recording visits to
patients' homes.
The National Provider Identifier (NPI) of facilities where
hospice patients are receiving care. Most commenters noted that it
would not be difficult to get this information and enter it into their
systems. A few commenters noted that sometimes patients are in more
than one facility type during a claim period, but that there is only
space for one NPI on the claim.
Post-mortem visits on the calendar day of death.
Commenters suggested we collect visit data for various timeframes after
the time of death, rather than the calendar day of death, since many
deaths occur late at night. They suggested we clarify what we mean by
time of death (time death actually occurs, or time the death is
pronounced). Several commenters suggested we gather post-mortem visit
data regardless of level of care or site of service.
Any durable medical equipment (DME) provided by the
hospice. Some commenters indicated that this would be difficult to
collect and record on claims. Many indicated that DME suppliers bill
them monthly, and waiting for the DME invoice would cause a delay in
submission of their claims. They also noted that it would take a great
deal of lead time to set this up with suppliers and software vendors to
track DME at the patient level. A few suggested that we use aggregate
data on DME costs from the cost reports instead.
Non-routine supplies provided by the hospice. Most
commenters indicated that this would be difficult to collect and record
on claims. A number of commenters wrote that their software does not
accommodate such reporting, and that it would create an additional
burden on clinical staff to track these items. Several mentioned that
it would take some lead time to modify existing systems to enable
hospices to track and report this information accurately. A few
suggested we use aggregate data on non-routine supplies from the cost
reports instead.
Drugs (injectable, non-injectable, and over-the-counter)
provided by the hospice. Most commenters indicated that this would be
difficult to collect and record on claims. Several asked if injectable
drugs include infusion pumps, which is considered DME. Several
commenters noted that the hospice staff person is not always the person
administering drugs, making tracking more complicated; they suggested
focusing on the fills, rather than drugs administered. Some wrote that
hospices get their drugs from multiple pharmacies, making reporting
more difficult due to inconsistencies in pharmacy billing. Others wrote
that their data systems are not able to track drugs by patient, and
suggested that we use aggregate data from the cost reports instead.
Some noted that they purchase some drugs in larger quantities, making
reporting at the patient level more complicated. A few noted that this
could be done, but said that hospices would need lead time to prepare
systems to track and report at the patient level. One suggested that we
specify what cost structure drug charges should be based upon, such as
average wholesale price plus a percentage.
In summary, commenters were largely supportive of our suggestions
to collect additional visit and NPI data on claims. Many suggested
collecting data on DME, supplies, and drugs from the cost reports,
rather than at the patient level. Several commenters reminded us that
their primary focus is patient care, and were concerned about the cost
of such data collection. We appreciate the comments submitted, and will
consider this input as we move forward towards implementing any new
data collection for hospices. We issued Change Request 8358 on Friday,
July 26, 2013 detailing the new data collection requirements.
Section 3132(a)(1)(C) of the Affordable Care Act also authorizes us
to collect more data on hospice cost reports. The revisions to the
hospice cost report and its associated instructions are described in
detail in a revision to the information collection request currently
approved under OMB control number 0938-0758. As required by the
Paperwork Reduction Act, we published the both 60-day and 30-day
notices with comment periods in the Federal Register on April 29, 2013
(78 FR 25089).
The proposed rule did not solicit comments on our hospice payment
reform updates and discussions, but we received 54 comments on this
section. We thank the commenters for their input and we will consider
the comments received as we move forward with hospice payment reform.
E. Technical and Clarifying Regulations Text Change
We proposed to incorporate the following technical change to
correct an erroneous cross reference in our regulations text.
Administrative Appeals (Sec. 418.311)
A hospice that does not believe its payments have been properly
determined may request a review from the intermediary or from the
Provider Reimbursement Review Board (PRRB), depending on the amount in
controversy. Section 418.311 details the procedures for appealing a
payment decision and also refers to 42 CFR part 405, subpart R. The
rationale for this appeals process was explained in the
[[Page 48276]]
August 22, 1983 Hospice proposed rule (48 FR 38146) and finalized in
the December 16, 1983 Hospice final rule (48 FR 56008). Hospices are
permitted to appeal computation of the payment limit or the amount due
to the hospice to the PRRB if the amount in controversy is $10,000 or
more.
We made a technical correction in Sec. 418.311 to correct an
erroneous reference to Sec. 405.1874. The published reference to Sec.
405.1874 does not exist and was a typographic error. We are correcting
this error by changing the referenced Sec. 405.1874 to Sec.
405.1875--Administrator review. Section 405.1875 allows for the
Administrator, at his or her discretion, to immediately review any
decision of the Board as described in the August 22, 1983 proposed and
December 16, 1983 final rules (48 FR 38159, and 48 FR 56019,
respectively).
We received no comments on this proposed technical correction, and
are implementing the correction as proposed.
V. Collection of Information Requirements
Under the Paperwork Reduction Act of 1995, we are required to
provide 60-day notice in the Federal Register and solicit public
comment before a collection of information requirement is submitted to
the Office of Management and Budget (OMB) for review and approval. In
order to fairly evaluate whether an information collection should be
approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act
of 1995 requires that we solicit comment on the following issues:
The need for the information collection and its usefulness
in carrying out the proper functions of our agency.
The accuracy of our estimate of the information collection
burden.
The quality, utility, and clarity of the information to be
collected.
Recommendations to minimize the information collection
burden on the affected public, including automated collection
techniques.
We solicited public comment on each of these issues for this
section of this document that contains information collection
requirements (ICRs).
Section 1814(i)(5)(C) of the Act requires that each hospice submit
data to the Secretary on quality measures specified by the Secretary.
Such data must be submitted in a form and manner, and at a time
specified by the Secretary. Under section 1814(i)(5)(D)(iii) of the
Act, the Secretary must publish selected measures that will be
applicable with respect to FY 2014 not later than October 1, 2012. In
implementing the Hospice quality reporting program, we seek to collect
measure information with as little burden to the providers as possible
and which reflects the full spectrum of quality performance.
We proposed and will implement a Hospice Experience of Care Survey
to reflect the patients' families' and friends' perspectives of care in
hospices. The 60-day notice for the field test of the survey was
published on April 4, 2013 (78 FR 20323) under CMS-10475 (OCN 0938-
New). While we set out the requirements and burden estimates for the
field study, it is too early to set out the requirements and burden
estimates for the national implementation of the survey. We anticipate
having the final survey instrument in 2014 and setting out the
collection of information requirements and burden estimates in the
proposed rule for CY 2015. We will implement the survey in 2015.
In this final rule we are requiring implementation of a hospice
patient-level item set to be used by all hospices to collect and submit
standardized data on each patient admitted to hospice. This Hospice
Item Set will be used to support the standardized collection of the
requisite data elements to calculate quality measures. Hospices will be
required to complete and submit an admission HIS and a discharge HIS on
all patients admitted to hospice starting July 1, 2014 for FY 2016 APU
determination. The admission and discharge HIS will collect the
standardized data elements needed to calculate 7 NQF endorsed measures
for hospice.
Using 2011 Medicare claims data we have estimated that there will
be approximately 1,089,719 admissions across all hospices per year and
therefore, we expect that there should be 1,089,719 Hospice Item Sets
(consisting of one admission and one discharge item set per patient),
submitted across all hospices yearly. There were 3,742 certified
hospices in the U.S. as of October 1, 2012; we estimate that each
individual hospice will submit on average 291 Hospice Item Sets
annually or 24 Hospice Items Sets per month.
The Hospice Item Set consists of both an admission and a discharge
data collection. As noted above, we estimate that there will be
1,089,719 hospice admissions across all hospices per year. Therefore,
we expect there to be 2,179,438 Hospice Item Set submissions, (both
admission and discharge data) submitted across all hospices annually or
181,620 across all hospices monthly. We further estimate that there
will be 582 Hospice Item Set submissions by each hospice annually or 49
submissions monthly.
For the Admission Hospice Item Set, we estimate that it will take
14 minutes of time by a clinician such as a Registered Nurse at an
hourly wage of $33.23 to abstract data for Admission Hospice Item Set.
This will cost the hospice approximately $7.75 for each admission
assessment.\9\ We further estimate that it will take 5 minutes of time
by clerical or administrative staff person such as a medical data entry
clerk or medical secretary at an hourly wage of $15.59 to upload the
Hospice Item Set data into the CMS system. This will cost the hospice
approximately $1.30 per assessment.\10\ For the Discharge Hospice Item
Set, we estimate that it will take 5 minutes of time by a clinician
such as a nurse at an hourly wage of $33.23 to abstract data for
Discharge Hospice Item Set. This will cost the hospice approximately
$2.77. We further estimate that it will take 5 minutes of time by
clerical or administrative staff such as a medical data entry clerk or
medical secretary at an hourly wage of $15.59 to upload data into the
CMS system. This will cost the hospice approximately $1.30.
---------------------------------------------------------------------------
\9\ 14 minutes of time by a Registered Nurse at $33.23/60
minutes per hour = $0.56; $0.56 per one minute x 5 minutes = $7.75.
\10\ 5 minutes of time by a Medical Data Entry Clerk at $15.59/
60 minutes per hour = $0.265; $0.265 per one minute x 5 minutes =
$1.30.
---------------------------------------------------------------------------
We estimate that the total nursing time required for completion of
both the admission and discharge assessments is 19 minutes at a rate of
$33.23 per hour. The annualized cost across all Hospices for the
nursing/clinical time required to complete both the admission and
discharge Hospice Item sets is estimated to be $11,458,528 and the cost
to each individual Hospice is estimated to be $3,062.14. The estimated
time burden to hospices for a medical data entry clerk to complete the
admission and discharge Hospice Item Set assessments is 10 minutes at a
rate of $15.59 per hour. The cost for completion of the both the
admission and discharge Hospice Item sets by a medical data entry clerk
is estimated to be $2,829,401 across all Hospices and $756.12 to each
Hospice.
The total combined time burden for completion of the Admission and
Discharge Hospice Data Item Sets is estimated to be 29 minutes. The
total annualized cost across all hospices is estimated to be
$14,287,929. For each individual hospice, this annualized cost is
estimated to be $3,818.26. The estimated cost for each individual
Hospice Item Set submission is $13.11.
[[Page 48277]]
Comment: We received several comments indicating concern about
general burden that would be associated with implementing and using the
HIS. Commenters stated hospices will have to conduct training among
staff to implement and use the HIS, in addition to staff time that will
be required to complete and submit the HIS. Commenters also stated that
implementing the HIS will require modifications to clinical
documentation processes. Some commenters expressed concerns that
implementing the HIS will concurrently entail both implementation of a
new data collection tool and implementation of new quality measures. No
commenters stated that these burdens were great enough to consider not
implementing the HIS for use in the HQRP.
Response: We recognize these activities and efforts will be
required to implement and use the HIS as part of the quality reporting
program. We agree that it is important for Hospices to learn about and
understand the new HIS and we plan to provide hospices with training
resources to facilitate implementation of the HIS. We further
acknowledge that specific training costs were not identified in the
proposed rule because calculating the training burden is outside the
scope of the information collection requirements.
Comment: A few commenters expressed concern that the estimated 29
minutes to complete and upload the admission and discharge HIS was
underestimated. One commenter said that the estimated 14 minutes for a
staff member to extract data for the Admission HIS and 5 minutes for
the Discharge HIS seemed accurate, another commenter indicated that,
based on their experiences with the Home Health OASIS, they felt the
HIS would take longer than the estimated time.
Response: Burden estimates for completing the HIS data items were
based on the HIS pilot test. The HIS is a set of data elements that can
be used to calculate 7 NQF endorsed quality measures. The HIS is not a
patient assessment that would be administered to the patient and/or
family or caregivers during the initial assessment visits; therefore,
it cannot be compared to the OASIS instrument. As the HIS is not a true
patient assessment, the estimated burden of 14 and 5 minutes do not
include the time a clinician would spend assessing the patient. The
time estimates are intended to reflect the time it would take hospice
staff to complete and submit the HIS, irrespective of clinical
activities to collect initial assessment data. The HIS pilot
demonstrated that hospices use varying patient assessment forms during
the initial patient assessment; all hospices were able to crosswalk
items from their hospice's patient assessment forms to the HIS data
elements, and complete the HIS items. Therefore, the HIS did not add
new data collection efforts to the hospice's customary patient initial
assessment.
VI. Regulatory Impact Analysis
A. Statement of Need
This final rule follows Sec. 418.306(c), which requires annual
issuance, in the Federal Register, of the hospice wage index based on
the most current available CMS hospital wage data. This rule finalizes
hospice payment rates for FY 2014. In addition, this final rule
provides background on hospice care, clarifies diagnosis coding on
hospice claims, updates the public on the status of hospice payment
reform, finalizes a technical and clarifying regulatory text change,
and finalizes changes to the hospice quality reporting program.
B. Overall Impact
The overall impact of this final rule is an estimated net increase
in Federal payments to hospices of $160 million, or 1.0 percent, for FY
2014. This estimated impact on hospices is a result of the final
hospice payment update percentage for FY 2014 of 1.7 percent and
changes to the FY 2014 hospice wage index, including a reduction to the
BNAF by an additional 15 percent, for a total BNAF reduction of 70
percent (10 percent in FY 2010, and 15 percent per year for FY 2011
through FY 2014). A 70 percent reduced BNAF is computed to be 0.018461
(or 1.8461 percent). The BNAF reduction is part of a 7-year BNAF phase-
out that was finalized in the August 6, 2009 FY 2010 Hospice Wage Index
final rule (74 FR 39384), and is not a policy change.
1. Introduction
We have examined the impacts of this rule as required by Executive
Order 12866 on Regulatory Planning and Review (September 30, 1993),
Executive Order 13563 on Improving Regulation and Regulatory Review
(January 18, 2011), the Regulatory Flexibility Act (RFA) (September 19,
1980, Pub. L. 96-354), section 1102(b) of the Act, section 202 of the
Unfunded Mandates Reform Act of 1995 (UMRA, March 22, 1995; Pub. L.
104-4), and the Congressional Review Act (5 U.S.C. 804(2)).
Executive Orders 12866 and 13563 direct agencies to assess all
costs and benefits of available regulatory alternatives and, if
regulation is necessary, to select regulatory approaches that maximize
net benefits (including potential economic, environmental, public
health and safety effects, distributive impacts, and equity). Executive
Order 13563 emphasizes the importance of quantifying both costs and
benefits, of reducing costs, of harmonizing rules, and of promoting
flexibility. A regulatory impact analysis (RIA) must be prepared for
major rules with economically significant effects ($100 million or more
in any 1 year). This final rule has been designated as economically
significant under section 3(f)(1)of Executive Order 12866 and thus a
major rule under the Congressional Review Act. Accordingly, we have
prepared a regulatory impact analysis (RIA) that to the best of our
ability presents the costs and benefits of the rulemaking. Also, the
rule has been reviewed by OMB.
2. Detailed Economic Analysis
This final rule sets forth updates to the FY 2013 hospice payment
rates. The impact analysis of this final rule presents the estimated
expenditure effects of policy changes finalized in this rule. Certain
events may limit the scope or accuracy of our impact analysis, because
such an analysis is susceptible to forecasting errors due to other
changes in the forecasted impact time period. The nature of the
Medicare program is such that the changes may interact, and the
complexity of the interaction of these changes could make it difficult
to predict accurately the full scope of the impact upon hospices.
Table 11 represents how hospice revenues are likely to be affected
by the policy changes finalized in this rule. In column 1 of Table 11,
we indicate the number of hospices included in our analysis as of
December 31, 2012, which had also filed claims in FY 2012. In column 2,
we indicate the number of routine home care days that were included in
our analysis, although the analysis was performed on all types of
hospice care. Column 3 shows the percentage change in estimated
Medicare payments for FY 2014 due to the effects of the updated wage
data only, compared with estimated FY 2013 payments. The effect of the
updated wage data can vary from region to region depending on the
fluctuations in the wage index values of the pre-floor, pre-
reclassified hospital wage index. Column 4 shows the percentage change
in estimated hospice payments from FY 2013 to FY 2014 due to the
combined effects of using the updated wage data and reducing the BNAF
by an additional 15 percent. Column 5 shows the percentage change in
estimated hospice
[[Page 48278]]
payments from FY 2013 to FY 2014 due to the combined effects of using
updated wage data, an additional 15 percent BNAF reduction, and the
final 1.7 percent hospice payment update percentage. Taking into
account the 1.7 percent final hospice payment update percentage (+$280
million), the use of updated wage index data ($-20 million), and the
additional 15 percent reduction in the BNAF ($-100 million), hospice
payments will increase by an estimated $160 ($280 million-$20 million -
$100 million = $160 million) or 1.0 percent in FY 2014.
The impact of changes in this final rule has been analyzed
according to the type of hospice, geographic location, type of
ownership, hospice base, and size. Table 11 categorizes hospices by
various geographic and hospice characteristics. The first row of data
displays the aggregate result of the impact for all Medicare-certified
hospices. The second and third rows of the table categorize hospices
according to their geographic location (urban and rural). Our analysis
indicated that there are 2,594 hospices located in urban areas and 975
hospices located in rural areas. The next two row groupings in the
table indicate the number of hospices by census region, also broken
down by urban and rural hospices. The next grouping shows the impact on
hospices based on the size of the hospice's program. We determined that
the majority of hospice payments are made at the routine home care
rate. Therefore, we based the size of each individual hospice's program
on the number of routine home care days provided in FY 2012. The next
grouping shows the impact on hospices by type of ownership. The final
grouping shows the impact on hospices defined by whether they are
provider-based or freestanding.
Column 5 of Table 11 shows the combined effects of the updated wage
data, the additional 15 percent BNAF reduction, and the final 1.7
percent hospice payment update percentage on estimated FY 2014 payments
as compared to estimated FY 2013 payments. Overall, hospices are
anticipated to experience a 1.0 percent increase in payment, with urban
hospices anticipated to experience a 1.0 percent increase in payments,
and rural hospices anticipated to experience 1.1 percent increase in
payments. Urban hospices are anticipated to experience an increase in
estimated payments in every region, ranging from 0.3 percent in the
Mountain region to 2.2 percent in New England. Rural hospices in every
region but one are estimated to see an increase in payments ranging
from 0.4 percent in New England to 1.7 percent in the East South
Central and Outlying region. The Pacific region is estimated to see a
decrease in payments of 1.2 percent, largely due to fluctuations in the
updated hospital wage index data used to create the FY 2014 hospice
wage index. Hospital wages in the Pacific region declined compared to
the previous year, which led to the decrease in the hospital wage index
values, and which thus affected the FY 2014 hospice wage index values.
Column 5 of Table 11 also shows an estimated payment increase by
hospice base and hospice size. Payments to hospices in FY 2014 are
estimated to increase by 1.4 percent for HHA-based hospices, 1.1
percent for hospital-based hospices, 1.0 percent for SNF-based
hospices, and by 0.9 percent for freestanding hospices. Payments to
small hospices (less than 3,500 RHC days) in FY 2014 are estimated to
increase by 0.8 percent, whereas payments to large hospices (more than
20,000 RHC days) in FY 2014 are estimated to increase by 1.0 percent.
Table 11--Anticipated Impact on Medicare Hospice Payments in FY 2014 in Updating the Pre-floor, Pre-Reclassified
Hospital Wage Index Data, Reducing the Budget Neutrality Adjustment Factor (BNAF) by an Additional 15 Percent
(for a Total BNAF Reduction of 70 Percent) and Applying a 1.7 Percent Hospice Payment Update Percentage
----------------------------------------------------------------------------------------------------------------
Percent change
in hospice
Percent change payments due
in hospice to wage index
payments due update,
Number of Percent change to wage index additional 15%
Number of routine home in hospice update, reduction in
hospices care days in payments due additional 15% budget
thousands to the wage reduction in neutrality
index update budget adjustment and
neutrality hospice
adjustment payment
percentage
update
(1) (2) (3) (4) (5)
----------------------------------------------------------------------------------------------------------------
ALL HOSPICES.................... 3,569 62,945 -0.1 -0.7 1.0
URBAN HOSPICES.............. 2,594 55,101 -0.1 -0.7 1.0
RURAL HOSPICES.............. 975 7,844 -0.2 -0.6 1.1
BY REGION--URBAN:
NEW ENGLAND................. 129 1,472 1.1 0.5 2.2
MIDDLE ATLANTIC............. 249 5,702 0.0 -0.6 1.1
SOUTH ATLANTIC.............. 378 13,173 -0.7 -1.3 0.4
EAST NORTH CENTRAL.......... 338 7,224 0.0 -0.6 1.1
EAST SOUTH CENTRAL.......... 155 3,278 -0.5 -1.0 0.7
WEST NORTH CENTRAL.......... 197 2,494 0.4 -0.2 1.5
WEST SOUTH CENTRAL.......... 517 6,622 -0.4 -1.0 0.7
MOUNTAIN.................... 263 5,698 -0.8 -1.4 0.3
PACIFIC..................... 333 8,141 0.9 0.2 1.9
OUTLYING.................... 35 1,296 0.3 0.3 2.0
BY REGION--RURAL:
NEW ENGLAND................. 24 195 -0.7 -1.3 0.4
MIDDLE ATLANTIC............. 43 439 -0.1 -0.7 1.0
SOUTH ATLANTIC.............. 135 1,918 -0.3 -0.7 1.0
[[Page 48279]]
EAST NORTH CENTRAL.......... 138 1,154 0.4 -0.2 1.5
EAST SOUTH CENTRAL.......... 134 1,529 0.1 0.0 1.7
WEST NORTH CENTRAL.......... 182 604 -0.8 -1.2 0.5
WEST SOUTH CENTRAL.......... 176 977 -0.1 -0.2 1.5
MOUNTAIN.................... 95 568 0.4 -0.1 1.6
PACIFIC..................... 47 445 -2.2 -2.8 -1.2
OUTLYING.................... 1 15 0.0 0.0 1.7
BY SIZE/DAYS:
0-3499 DAYS (small)......... 841 1,373 -0.3 -0.8 0.8
3500-19,999 DAYS (medium)... 1815 17,403 -0.2 -0.7 1.0
20,000+ DAYS (large)........ 913 44,168 -0.1 -0.7 1.0
TYPE OF OWNERSHIP:
VOLUNTARY................... 1080 23,296 0.0 -0.5 1.1
PROPRIETARY................. 2002 32,992 -0.3 -0.9 0.8
GOVERNMENT.................... 487 6,656 -0.1 -0.7 1.0
HOSPICE BASE:2
FREESTANDING................ 2569 50,665 -0.2 -0.8 0.9
HOME HEALTH AGENCY.......... 522 7,728 0.3 -0.3 1.4
HOSPITAL.................... 458 4,430 0.0 -0.6 1.1
SKILLED NURSING FACILITY.... 20 122 0.0 -0.7 1.0
----------------------------------------------------------------------------------------------------------------
Source: Provider data as of December 31, 2012 for hospices with claims filed in FY 2012 (Based on the 2012
standard analytic file (SAF).
Note(s): The final 1.7 percent hospice payment update percentage for FY 2014 is based on an estimated 2.5
percent inpatient hospital market basket update, reduced by a 0.5 percentage point productivity adjustment and
by 0.3 percentage point; these reductions were mandated by section 3401(g) of ACA.
REGION KEY:
New England = Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont; Middle Atlantic =
Pennsylvania, New Jersey, New York; South Atlantic = Delaware, District of Columbia, Florida, Georgia,
Maryland, North Carolina, South Carolina, Virginia, West Virginia; East North Central = Illinois, Indiana,
Michigan, Ohio, Wisconsin; East South Central = Alabama, Kentucky, Mississippi, Tennessee; West North Central
= Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota; West South Central = Arkansas,
Louisiana, Oklahoma, Texas; Mountain = Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming;
Pacific = Alaska, California, Hawaii, Oregon, Washington; Outlying = Guam, Puerto Rico, Virgin Islands
3. Cost Allocation of Quality Reporting
This final rule also implements a hospice patient-level data set to
be used by all hospices to collect and submit standardized data about
each patient admitted to hospice. This Hospice Item Set will be used to
support the standardized collection and calculation of quality
measures, collection of the requisite data elements. Hospices will be
required to complete and submit an admission HIS and a discharge HIS on
all patients admitted to hospice starting July 1, 2014 for FY 2016 APU
determination. The admission and discharge HIS will collect the
standardized data elements needed to calculate 7 NQF endorsed measures
for hospice. The total annualized cost across all hospices, starting
July 2014, is estimated to be $14,287,929. Furthermore, the structural
measure related to QAPI indicators and the NQF 0209 pain
measure will no longer be required for the hospice quality reporting
program beyond data submission for the FY 2015 payment determination.
The original intent of the structural measure was for hospices to
submit information about number, type, and data source of quality
indicators used as a part of their QAPI Program. Data gathered as part
of the structural measure were used to ascertain the breadth and
context of existing hospice QAPI programs to inform future measure
development activities including the data collection approach for the
first year of required reporting (FY 2014). Please refer to section B,
the Hospice Quality Reporting Program, for a detailed discussion of
these programs.
4. Alternatives Considered
In continuing the reduction to the BNAF by an additional 15
percent, for a total BNAF reduction of 70 percent (10 percent in FY
2010, and 15 percent per year for FY 2011 through FY 2014), and
implementing the hospice payment update percentage and the updated wage
index, the aggregate impact will be a net increase of $160 million in
payments to hospices. In the proposed rule for FY 2014, we did not
consider discontinuing the additional 15 percent reduction to the BNAF
as the 7-year phase-out of the BNAF was finalized in the FY 2010
Hospice Wage Index final rule (74 FR 39384). However, if we were
[[Page 48280]]
to discontinue the reduction to the BNAF by an additional 15 percent,
Medicare would pay an estimated $100 million more to hospices in FY
2014. The final 1.7 percent hospice payment update percentage for FY
2014 is based on a final 2.5 percent inpatient hospital market basket
update for FY 2014, reduced by a 0.5 percentage point productivity
adjustment and by an additional 0.3 percentage point. Payment rates for
FYs since 2002 have been updated according to section
1814(i)(1)(C)(ii)(VII) of the Act, which states that the update to the
payment rates for subsequent FYs must be the market basket percentage
for that FY. The Act requires us to use the inpatient hospital market
basket to determine the hospice payment rate update. In addition,
section 3401(g) of the Affordable Care Act mandates that, starting with
FY 2013 (and in subsequent FYs), the hospice payment update percentage
will be annually reduced by changes in economy-wide productivity as
specified in section 1886(b)(3)(B)(xi)(II) of the Act. In addition,
section 3401(g) of the Affordable Care Act also mandates that in FY
2013 through FY 2019, the hospice payment update percentage will be
reduced by an additional 0.3 percentage point (although for FY 2014 to
FY 2019, the potential 0.3 percentage point reduction is subject to
suspension under conditions specified in section 1814(i)(1)(C)(v) of
the Act). Since the hospice payment update percentage is determined
based on statutory requirements, we did not consider not updating
hospice payment rates by the payment update percentage.
C. Accounting Statement
As required by OMB Circular A-4 (available at https://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table 12 below, we
have prepared an accounting statement showing the classification of the
expenditures associated with this final rule. Table 12 provides our
best estimate of the increase in FY 2014 Medicare payments under the
hospice benefit as a result of the changes presented in this final rule
using data for 3,569 hospices in our database. In addition, the table
presents the costs to hospice providers for submitting data to the
Hospice Item Set starting in July 2014.
Table 12--Accounting Statement: Classification of Estimated
Expenditures, From FY 2013 to FY 2014
[In $millions]
------------------------------------------------------------------------
Category Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers............ $160.
From Whom to Whom......................... Federal Government to
Hospices.
------------------------------------------------------------------------
Category Costs
------------------------------------------------------------------------
Annualized Monetized Costs for Hospices to $14.3.
Submit Data*.
------------------------------------------------------------------------
* All hospices are required to submit data for the Hospice Item Set
starting in July of 2014.
D. Conclusion
In conclusion, the overall effect of this final rule is an
estimated $160 million increase in Federal Medicare payments to
hospices due to the wage index changes (including the additional 15
percent reduction in the BNAF) and the final hospice payment update
percentage of 1.7 percent. Furthermore, hospices are estimated to incur
total costs of $14.3 million as a result of data submission
requirements starting in July 2014. Lastly, the Secretary has
determined that this final rule will not have a significant impact on a
substantial number of small entities, or have a significant effect
relative to section 1102(b) of the Act.
1. Regulatory Flexibility Act Analysis
The RFA requires agencies to analyze options for regulatory relief
of small businesses if a rule has a significant impact on a substantial
number of small entities. For purposes of the RFA, we estimate that
almost all hospices are small entities as that term is used in the RFA.
The great majority of hospitals and most other health care providers
and suppliers are small entities by meeting the Small Business
Administration (SBA) definition of a small business (in the service
sector, having revenues of less than $7.0 million to $34.5 million in
any 1 year), or being nonprofit organizations. While the SBA does not
define a size threshold in terms of annual revenues for hospices, it
does define one for home health agencies ($14 million; see https://www.sba.gov/sites/default/files/files/Size_Standards_Table(1).pdf).
For the purposes of this final rule, because the hospice benefit is a
home-based benefit, we are applying the SBA definition of ``small'' for
home health agencies to hospices; we will use this definition of
``small'' in determining if this final rule has a significant impact on
a substantial number of small entities (for example, hospices). We
estimate that 95 percent of hospices have Medicare revenues below $14
million or are nonprofit organizations and therefore are considered
small entities.
HHS's practice in interpreting the RFA is to consider effects
economically ``significant'' only if they reach a threshold of 3 to 5
percent or more of total revenue or total costs. As noted above, the
combined effect of the updated wage data, the additional 15 percent
BNAF reduction, and the final FY 2014 hospice payment update percentage
of 1.7 percent results in an increase in estimated hospice payments of
1.0 percent for FY 2014. For small and medium hospices (as defined by
routine home care days), the estimated effects on revenue when
accounting for the updated wage data, the additional 15 percent BNAF
reduction, and the final FY 2014 hospice payment update percentage
reflect increases in payments of 0.8 percent and 1.0 percent,
respectively. Therefore, the Secretary has determined that this final
rule will not create a significant economic impact on a substantial
number of small entities.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis if a rule may have a significant impact on
the operations of a substantial number of small rural hospitals. This
analysis must conform to the provisions of section 604 of the RFA. For
purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a metropolitan
statistical area and has fewer than 100 beds. This final rule only
affects hospices. Therefore, the Secretary has determined that this
final rule will not have a significant impact on the operations of a
substantial number of small rural hospitals.
2. Unfunded Mandates Reform Act Analysis
Section 202 of the Unfunded Mandates Reform Act of 1995 also
requires that agencies assess anticipated costs and benefits before
issuing any rule whose mandates require spending in any 1 year of $100
million in 1995 dollars, updated annually for inflation. In 2013, that
threshold is approximately $141 million. This final rule is not
anticipated to have an effect on State, local, or tribal governments,
in the aggregate, or on the private sector of $141 million or more.
Comment: We received a few comments on Unfunded Mandates Reform Act
Analysis section. Commenters disagreed that we did not
[[Page 48281]]
meet the statutory threshold of the Unfunded Mandates Reform Act of
1995. A commenter stated that the total costs of additional staff time,
professional consulting fees and software necessary to comply fully
with the new billing; coding, quality reporting and survey
administration tasks will exceed that threshold figure of $141 million.
Response: The hospice benefit covers all care for the terminal
prognosis, related conditions, and for the management of pain and
symptoms. HIPAA, federal regulations, and the Medicare hospice claims
processing manual all require that ICD-9-CM Coding Guidelines be
applied to the coding and reporting of diagnoses on hospice claims. In
our regulations at 45 CFR 162.1002, the Secretary adopted the ICD-9-CM
code set, including The Official ICD-9-CM Guidelines for Coding and
Reporting. The CMS' Hospice Claims Processing manual (Pub 100-04,
chapter 11) requires that hospice claims include other diagnoses ``as
required by ICD-9-CM Coding Guidelines.'' In the proposed rule, we
provided guidance from the ICD-9-CM Official Guidelines for Coding and
Reporting to highlight coding guidelines for principal and other
diagnosis selection, as well as the various coding and sequencing
conventions found therein. We are not requiring any new ICD-9-CM coding
guidelines in this rule, rather we are reiterating existing policies
and reminding providers of the expectations in regards to diagnostic
coding on hospice claims. In addition, as indicated in section V of
this final rule, we set out the requirements and burden estimates for
the Hospice Experience of Care Survey field study and indicated that it
is too early to set out the requirements and burden estimates for the
national implementation of the survey. We anticipate having the final
survey instrument in 2014 and setting out the collection of information
requirements and burden estimates in the proposed rule for CY 2015. In
addition, we provided a burden estimate for the Hospice Item Set that
providers will be required to submit starting FY 2015, with a total
annualized cost across all hospices estimated at $14,287,929.
Therefore, we do not believe that any clarifications or requirements
promulgated in this rule exceed the Unfunded Mandates Reform Act
threshold.
VII. Federalism Analysis and Regulations Text
Executive Order 13132 on Federalism (August 4, 1999) establishes
certain requirements that an agency must meet when it promulgates a
proposed rule (and subsequent final rule) that imposes substantial
direct requirement costs on State and local governments, preempts State
law, or otherwise has Federalism implications. We have reviewed this
final rule under the threshold criteria of Executive Order 13132,
Federalism, and have determined that it will not have substantial
direct effects on the rights, roles, and responsibilities of States,
local or tribal governments.
List of Subjects in 42 CFR Part 418
Health facilities, Hospice care, Medicare, Reporting and
recordkeeping requirements.
For the reasons set forth in the preamble, the Centers for Medicare
& Medicaid Services proposes to amend 42 CFR part 418 as set forth
below:
PART 418--HOSPICE CARE
0
1. The authority citation for part 418 continues to read as follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
Sec. 418.311 [Amended]
0
2. Amend Sec. 418.311 by removing the reference to ``Sec. 405.1874''
and adding in its place the reference ``Sec. 405.1875''.
(Catalog of Federal Domestic Assistance Program No. 93.778, Medical
Assistance Program) (Catalog of Federal Domestic Assistance Program
No. 93.773, Medicare--Hospital Insurance; and Program No. 93.774,
Medicare--Supplementary Medical Insurance Program)
Dated: July 24, 2013.
Marilyn Tavenner,
Administrator, Centers for Medicare & Medicaid Services.
Approved: July 30, 2013.
Kathleen Sebelius,
Secretary, Department of Health and Human Services.
[FR Doc. 2013-18838 Filed 8-2-13; 4:15 pm]
BILLING CODE 4120-01-P
