Hospice Documenting Slow Decline Ask-the-Contractor Teleconference (ACT)
View the handout for the June 28, 2018, Hospice Documenting Slow Decline Ask-the-Contractor Teleconference (ACT).
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- For those hospice patients who do not have a chronic condition but are frail and very elderly (100+ years old), any suggestions as to how to document?
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Despite the patient's advanced age, decline still needs to be shown in the documentation. The older our patients get, they aren't going to have as much strength or lucidity, and may show increased sleep time. Try to show decline on some of those smaller details. In addition, when your documentation shows how many hours a day a patient is sleeping; please put the information in a 24 hour time period. For example, the patient is sleeping 16 hours out of 24 hours.
Published: 08.03.18
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- Could you please go over face-to-face documentation requirements, as far as clinical findings to determine continued hospice eligibility? How detailed should this clinical documentation be to meet face-to-face encounter requirements?
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What we're looking for on face-to-face documentation is evidence of decline. It's very helpful if you can compare the prior face-to-face to the current face-to-face encounter. Document what you are seeing that is different from last time. Go into as much detail as you possibly can on all the big AND little signs and symptoms.
Published: 08.03.18
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- Can you give a good example of Class IV symptoms?
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The official description of Class IV symptoms are:
- Unable to carry on any physical activity without discomfort.
- Symptoms of heart failure at rest.
- If any physical activity is undertaken, discomfort increases
Published: 08.03.18
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- What if you have a hospice patient that actually improves and gains weight, but is still terminal? Do we discharge and wait for the decline? E.g. a patient admitted weighing 70 pounds and then improves and gains weight to 86 pounds? The physician believes the patient is going to die within 6 months, but is improving not showing a slow decline…?
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You may have a patient who is improving by showing weight gain. But keep in mind they may gain weight because they're improving, or they may gain weight because they have edema. Be sure to document the reason for weight gain. We are looking for decline, if there isn't something else other than what you've mentioned that's showing decline, I would seriously consider discharging them. If decline isn't shown in your documentation, your claim probably won't be paid.
Published: 08.03.18
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- What do you mean by benefit being utilized as long term care benefit? If patient cannot decline any more - e.g. weight < 70 lbs. - how do we document that we expect them to have a very short prognosis despite symptoms?
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This is where you want to be sure and illustrate why you are showing a very short prognosis. Sometimes you have a patient who has declined as much as they can as far as weight loss, FAST score, etc. Look for other little details that show that they are still declining.
Published: 08.03.18
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- The LCD guidelines include a paragraph that states the patient is allowed to improve or not decline as long as the hospice believes that the patient has a six month or less prognosis. Please explain how we can get a reviewer to accept this?
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We are required to see decline in the documentation. There may be areas that are not declining. There should be something evident – maybe a small detail – that shows decline.
Published: 08.03.18
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- At times, patients do improve on hospice service and then they have to be discharged. Is this a "red flag" for CMS?
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No, it is not. We see you are doing a good job with accurate and complete documentation and you are paying close attention as to whether or not that patient still qualifies for hospice. When you discharge a patient you do so knowing another hospice agency is probably going to pick them up right away. Unfortunately that does happen. Use your good judgement as to whether or not that patient still qualifies for hospice services.
Published: 08.03.18
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- For cardiac patients referred by the primary care physician for cardiac issues with no NYHA, is this something the medical director can assess based on nurses' report?
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Yes that is allowable. The medical director does not have to actually see the patient, but based upon information given they can change the classification level if the physician feels it is appropriate to do so.
Published: 08.03.18
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- How long of a period of plateau is acceptable for these slow decline patients?
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There are not an exact number of days to use for this decision. Try to use common sense. While there is not an exact period time to be used, I would use a couple of weeks to look at whether or not the patient has plateaued and should they be discharged for now.
Published: 08.03.18
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- Nursing facility patients who have reached the end of possible weight loss, ADL function, FAST scale, verbal ability, etc. & clearly terminal - are often denied as custodial care due to no infection or skin wounds. Is elaborating on the steps taken to prevent infection or skin impairment helpful in these instances?
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Yes, and sometimes it is because of your excellent care that the patients are not showing some of the things we would normally look for to show decline. You want to make sure the patient is still showing decline. Sometimes you have to go in the small details to show why they're declining. You may want to consider that maybe they truly don't show they are appropriate to hospice for now and have a graduation from hospice party. When the patient starts to decline again they may be readmitted.
Published: 08.03.18
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- Why is CGS required to look for decline if this is not a regulation/condition of participation? I understand that the patient needs to be terminal and not chronic/custodial care needed, but a patient may not decline significantly but still be terminal and eligible for hospice care. Decline may difficult to see in patients with slow decline and the record being reviewed covers only a 30 day period.?
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That 30 day period may not show a significant amount of decline, but there still should be some sort of decline going on, which may not be evident or obvious.
Published: 08.03.18
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- So how do you chart for a patient with a history of coronary artery disease and hypertension but no heart failure, cancer or renal failure.?
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Heart failure, cancer or renal failure is not required to be present in a hospice patient. Chart the signs/symptoms your patient is exhibiting for their particular diagnosis.
Published: 08.03.18
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- On assessment the patient is declining, no longer talking or swallowing and is bed bound, however I can't really find a primary diagnosis.
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I would advise for you to work with the physician to determine a diagnosis.
Published: 08.03.18
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- The other struggle is those patients that go up and down- CHF especially. They can improve and decline in cycles and when you get to the cert period they may be in an upswing and doing well but in another 10 days things can change.
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This would be a good opportunity to make a graph or chart of some type to show that even though the patient is improving and decline, the chart is still showing a downward trend.
Published: 08.03.18
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- We had a dual eligible client on hospice audited a while ago; the reviewer stated we didn't provide lab test, x-rays, no infections like pneumonia/UTI or no decubitus ulcers. We don't typically run lab tests or do other diagnostic tests while on hospice, do others? Also, this client had extraordinary care with no decubitus or infections yet was less than 75 pounds and had pulses dipping into the 20s at times. What could have we documented to prevent this?
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The reviewer was not indicating that lab tests, etc. were required. They were giving you examples of things that might assist in showing decline if no other indicators were available. Documentation should focus on areas of decline even if there is no more weight to lose and with episodes of bradycardia.
Published: 08.03.18
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- We have another client at home with end stage Alzheimer's with a wife who dotes on him. He hasn't sat up independently or been able to say a word in almost 2 years. Staff that does not visit for some time can see a major decline between visits, but the staff who visit weekly struggle to see the minor changes. Any suggestions?
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It can be very difficult to see minor changes in a patient when you see them frequently. You may want to ask other staff members to visit the patient occasionally so those changes are evident. Ask those staff members what decline they are seeing and perhaps if you focus on those things the decline may be noticeable from one time to the next. Also any areas of measurement that can involve numbers may make it be more obvious when decline is evident. This may be weight, mid arm circumference, percentage of intake – both fluid and solid, amount of sleep, etc.
Published: 08.03.18
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