Hospice Blog Series Part 3 | Hospice Face-to-Face Encounters

Hospice Face-to-Face Encounters Update.

One year into hospice face-to-face encounters, and while we all have a better understanding of the requirements, the effort and pardon me, but downright drama it can take to get them completed is still more than I think we’d all like.

As you know as of 1/1/11 CMS implemented a requirement that necessitated patients on the Medicare hospice benefit have hospice face-to-face encounters within 30 days prior to the 180th day recertification (or third benefit period).  It must also take place within 30 days prior to every benefit period thereafter. The rules regarding who can perform the encounter, how it can be documented, etc. remain center stage for the challenges.

Most will agree that the value of having a physician see their patient during hospice care is beneficial.  In fact, I believe it was happening, with or without this rule.  There wasn’t however a structure for it occurring.  I understand the need for structure. Truly. I love an organized, systematic approach to things.  The issue that many agencies are facing has been to get the documentation completed.  It’s the paperwork! [Insert dramatic sigh!]

In the CMS-1355-F we have some relief coming from CMS. Specifically with regards to who can perform the hospice face-to-face encounters.  Now, any hospice physician can perform the face-to-face regardless of whether that physician is the same one who is recertifying the patient’s condition of terminal illness.  This is good news!  In fact CMS noted that all 15 commenters supported this action. Of course, we asked for more.  You can’t blame a hospice for trying, right? =) The request was to add Physician Assistants (PAs) and Clinical Nurse Specialists (CNSs) to the list of healthcare professionals that could conduct the face-to-face.  CMS responded to this by indicating that PAs and CNSs are not authorized by the Affordable Care Act to perform the face-to-face visit.  Their position is, without a change in the law, they can’t adopt a policy to allow for that kind of change. This was the same response for allowing community physicians and NPs to conduct the face-to-face and report their findings to a physician employed by the hospice.  The requirement remains that the person conducting the face-to-face must be employed or working under arrangement with a hospice (i.e. contracted).

This led into the next set of clarifications in the rule.  What exactly does it mean to be “employed” by a hospice?  CMS defines this as:

Employee means a person who:

1. Works for the hospice and for whom the hospice is required to issue a W-2 form on his or her behalf;
2. If the hospice is a subdivision of an agency or organization, an employee of the agency or organization who is assigned to the hospice;
3. Is a volunteer under the jurisdiction of the hospice.

The complete definition can be found at here at {42 CFR 418.3}.

Additionally there was clarification on the time period for which the face-to-face is to take place.  CMS thought that there was ambiguity surrounding how long after the start of the third benefit period a face-to-face could take place. The answer is, it’s supposed to happen before the start of the third benefit period but no more than 30 days prior.  No significant change here, just clarification to the original rule.

The final piece for face-to-face, effective 1/1/2012 and to be implemented by 1/9/2012, is in regards to what should occur when the face-to-face encounter does not occur timely.  CMS has indicated that when a face-to-face encounter does not occur within the 30 days prior to the third benefit period (or any subsequent benefit period) the patient is no longer considered terminally ill and therefore is not eligible for the Medicare hospice benefit.  As such, the hospice is required to discharge the patient but can re-admit them once the encounter has been completed.  CMS specifically noted that use of occurrence code 77 is not permitted.  (Some agencies were using Occurrence Code 77 to represent the non-billable days if the certification criteria were not documented in a timely fashion.)

CMS did state that an agency can choose to provide care to these patients in the interim at the agency’s expense until eligibility is re-established.  That care must occur outside of the Medicare hospice benefit.

It’s clear that change continues for face-to-face.

• How is your agency faring with this nearly 12 month old rule?
• Is it a non-issue?
• If you’re feeling pretty good about your process do you have any suggestions for agencies that are struggling?