CMS drastic 180 degree turn on Debility/Failure to Thrive
October 15, 2013
Undoubtedly by now you have all heard the news regarding CMS's "Clarification" in the Proposed payment updates for hospice released 10 days ago. Buried in the payment updates, CMS released a lengthy direction to hospices that the non-specific diagnoses, such as Debility or Adult Failure to Thrive should never be used as a primary diagnosis. Please take time to read the excerpt from this proposal, which I have attached for your convenience. This is in direct contradiction to the Medicare Administrative Contractors (MACs) policies, practices and education in the past. Palmetto has a Local Coverage Determination (LCD) called "Adult Failure to Thrive", which outlines and guides hospices of symptoms and characteristics of patients who most likely are within a six-month prognosis due to a multi-system failure, and the other three hospice MACs have an LCD called "Decline", which allows a culmination of the decline of a patient, and was typically used for patients when there was not a more specific disease process outstanding. This portion of the LCD was typically used with patients who had a diagnosis of either Debility NOS, or Adult Failure to Thive.
During the CMS Open Door Forum call last week, CMS stated that this was not a "new" stance by CMS, but the clarification was published due to the growth and "misuse" of these non-specific diagnoses, and the lack of secondary diagnoses listed on hospices claims. It was brought to CMS's attention at one point by a questioner from a hospice association that this was in direct contrast with their own MAC's policies and former directions. CMS replied that they were formulating formal instructions to the MACs, which should be published "soon" to ensure consistency. It was also discussed that CMS is looking to initiate an FISS edit which will return all hospice claims with these diagnoses to the provider for correction. There was no timeframe for this, but we can assume it will take several months, as CMS has to pubish instructions to the MACs, the MACs must change their own policies and/or procedures, and the edit must be initiated in FISS, which usually involves additional "releases" and education to the provider community.
Where did this complete change come from? CMS cites the hospice community for not including the "whole picture" of the patient's prognosis on the claim. Last year, CMS reminded agencies to include any co-morbidities on the claim- and expected multiple diagnoses on every patient. CMS's position is that hospice agencies, after doing a comprehensive assessment should note all of the diagnoses that are contributing to the patient's six-month prognosis, and these all should be included in the claim. The question was asked on the Open Door Forum "Would hospice agencies then be responsible for all of the care, medications and equipment for all of these included diagnoses?" CMS cited the Final Rule from the original Hospice Rule in 1983, and stated that "Yes", hospices are responsible for all care of the patient related to the terminal prognosis (not diagnosis) and the related conditions.
So, this is a huge shift for most hospices. What are our next steps?
1.) First, start the conversation at your agency.staff. Educate of the changes that will be made in the near future.
2.) Don't panic and get orders to change every patient's diagnosis immediately. This needs to be done with a complete assessment, and an IDG input. A responsible plan is to begin now to avoid utilization of these diagnoses at the start of care, and as each patient comes up for recert, review the diagnoses (which you are doing currently), and as in IDG, discuss the most prevalent symptoms and change the diagnosis at the time of recert to a more specific diagnosis.
3.) Continue to use Failure to Thrive or Debility as appropriate as a secondary diagnosis. This is descriptive of the trajectory of the illnesses as a whole.
4.) Provide feedback to CMS. Do you think this will impact access to care? Provide examples where FTT is the most appropriate diagnosis, in cases when no specific diagnoses alone meet the LCD criteria. Provide feedback regarding the plan for the RTP action, and a reasonable timeframe to allow providers to make the prescribed changes.
1. Electronically. You may submit electronic comments on this regulation to