HospiceDocumentation forNursesMore than Just "Painting the Picture”

Discuss the regulatory environment and how it relates todocumentationObjectives Identify documentation risk areas and common errors Demonstrate examples of strategies to improve documentationand minimize documentation pitfalls

42 CFR 418.20 Eligibility Requirements: In order to be eligible to elect hospice care under Medicare, anindividual must be:TheRegulatoryStandard Entitled to Part A of Medicare Certified as being terminally ill in accordance with §418.22 Elected for a palliative versus curative approach 42 CFR 418.2 DefinitionsTerminally ill means that the individual has a medicalprognosis that his or her life expectancy is 6 months orless if the illness runs its normal course Although only a MD can certify a patient as terminally ill with aprognosis of 6 months or less, the RN can assess for the patient’ssigns/symptoms of a terminal trajectory in functional decline atthe end of life. The RN can support the patient’s ongoing hospiceeligibility with appropriate documentation.

RegulatoryClimate: Who’sAuditingHospice? Hospice agencies are under increased scrutiny from Third Partypayers, Federal agencies, State agencies, and the MedicareAdministrative Contractor (MAC). MACs are the intermediaries between individual agencies and CMS. AMAC is a private health care insurer that has been awarded ageographic jurisdiction (map below) to process Medicare Part A andPart B claims. CMS relies on a network of MACs to serve as the primary operationalcontact between the Medicare program and individual providers (i.e.,hospice agencies) enrolled in the Medicare Program.

RegulatoryClimate: Who’sAuditingHospice? MACs can conduct different types of audits, including: Service-specific (hospice, home health, etc.) Provider-specific (a particular provider) – Targeted Probe andEducate (TPE) Data-generated (Looking for “outlier data” such as noncancer diagnosis with long length of stay, patients onextended levels of higher care such as GIP, concentratedlocations of care such as majority of patients in AssistedLivings vs. Home pts.) Every hospice is at risk for medical review from their MAC, andmore and more hospice providers are being audited. MACs audit documentation to look for deficiencies andinconsistencies such as: Documentation that does not support patient eligibility (i.e.,documentation doesn’t support prognosis of 6 months or less)AND/OR Technical errors that preclude billing/payment such as unsignedCertification Documents, Missing Verbal Certifications, etc.

Remember in nursing school when you learned, “If it’s notdocumented, it wasn’t done?”RegulatoryClimate: Who’sAuditingHospice? In hospice, if it’s not documented not only is it not done, but poordocumentation quality or documentation that omits key elementscan trigger payment scrutiny! Payment scrutiny means that payment for hospice services for ahospice claim can be withheld or denied based on eligibility ortechnical deficiencies. This can add up quickly and be incrediblycostly for a hospice! Solid documentation free of technical deficiencies andsupportive of patient eligibility is our best and onlydefense when it comes to payment-related scrutiny.

DocumentationFoundations:The Purpose The purposes of documentation include: Verifying quality and coordination of care Ensuring Continuity of Care Demonstrating compliance with federal/ state regulations aswell as accrediting organizations Providing substantiation of care if called into the court of law Providing the basis for payment for services

Compliant andSuccessfulSuncrest thatcontinues todeliverexceptional EOLcare!DocumentationFoundations:The PurposeThorough,Descriptive, andConsistentDocumentationGreaterCoordination ofCare for BetterPatient OutcomesMinimizes Riskwith DefensibleClaimsPositive Survey orAudit Outcomes

Each narrative note within thepatient’s record should “stand alone”and tell a thorough and completestory. Each note should contain:DocumentationContent The primary diagnosis Location/Environment of patient(pt lying in bed, pt up inwheelchair in common area, etc.) Pt. appearance (pt. appearedcachectic, frail, etc.) Assessment of patient’s condition(pain, symptoms, dyspnea, etc.) Pertinent assessment tools (MAC,PPS, FAST, etc.) Appetite (intake %) Current ADLs ability (and how thisis different from previous visits) Interventions and patient/familyresponse to care Review of medications Changes in cognition and level ofconsciousness Sleep frequency Goals of care and any adjustmentsto Plan of Care based onassessment findings and pt/MDPOAcollaboration Patient/family communication,including any education Communication with IDT team andany caregivers, attending MD, etc. Plans/Goals for follow-up care

What about the LCDS? Local Coverage Determinations (LCDs) are: Developed by each MAC Hospice Guidelines for eligibility (although not alwaysconsistent predictors of prognosis)DocumentationContent If a patient meets LCD criteria, they are deemed eligible. If not, apatient may still be eligible for the hospice benefit even if he/shedoesn’t meet the LCD criteria. In these cases, the MD must documentwhy the patient is eligible and ongoing supportive documentation bythe IDT team furthers the case. Not the legal standard for hospice eligibility but are used bygovernment contractors (i.e., MAC auditors) when reviewingmedical records Inconsistencies with the LCDs can be a red flag to an auditor and canlead to further scrutiny including withholding or denying a claim. Use the LCDs as a reference each time you document! Doing sohelps support the case for a patient’s ongoing hospice eligibility.

DocumentationQuality:CommonProblems Common documentation problems include: Using the wrong tool(s) for patient or diagnosis (or not usinga tool at all) Ex. Omitting a PPS score or incorrectly using the FASTscale with a patient whose primary dx is Metastatic LungCancer Inconsistencies among clinician scoring: The Hospice MD documents the patient as a FAST 7Cwhile the RNCM documents patient as FAST 7A Not identifying scores that don’t make sense or are in conflictwith others Ex. RNCM documents pt at FAST 7B but narrativestates “pt was talkative” without further explanationor description

DocumentationQuality:CommonProblems Common documentation problems include (continued): Using Terms that describe lack of decline or “stabilization”such as: Stable No change Eating well No issues noted No changes to POC (Remember, the POC is fluid andalways changing based on patient’s needs!) Using vague terms: “poor appetite” (use % instead) Using generalizations without explanation: “appears weaker” Needs “as evidenced by” “Pt appeared weaker aeb pt walking with walkerusing slow shuffled gait and has to stopapproximately every 30 feet to rest.”

Whenever possible, use Comparative Documentation tostrengthen the narrative note.DocumentationQuality:ComparativeDocumentation Comparative Documentation: Contrasts the patient’s present condition to his/her priorcondition Individualizes patients by focusing on their trajectory ofdecline Presents specific information, not generalizations Ex: One week ago, patient was eating ½ - ¾ of 2 mealsper day. Now eating only ¼ to 1 meal each day. Ex. Six months ago, pt was ambulating with walker andstandby assist. Pt is now wheelchair bound and requires 1person assist with transfer from bed to wheelchair. Ex: Patient weighed 140 lbs on admission. Today patientweighs 130lbs.

Assessment scales and tools are a key documentation elementand when used correctly help “paint the picture” of the patient’sterminal trajectory.DocumentationQuality: UsingScales Correctly Assessment tools include: LCDsPPSFASTNYHAADLsNutritional measurements (MAC, BMI, Weight)

Keys to Remember with the PPS:Using the PPS Determine score by reading horizontallyfrom the left Start with Ambulation on Left hand sideand read downward until the patient’sappropriate ambulation level is reached Then move to self-care column anddetermine self care Ambulation and Self Care are moreeasily discernable so these 2 are goodplaces to start Evaluate all 5 columns to determine score In general, the columns on the left arestronger determinants and takeprecedence over others Exception is that to be a PPS 30%, thepatient MUST require total care A pt who is “totally bed bound” butcan assist in their own self care wouldbe a 40%

The FAST Scale is a 16-itemscale designed to parallel theprogressive activitylimitations associated withAlzheimer’s DiseaseUsing theFAST Scale Designed for Alzheimer’sDisease and should only beused with Alzheimer’s Stage 7 identifies theminimum of activity limitationthat would support a 6 monthprognosis Refer to the LCD Guidelines:To qualify under Alzheimer'sDisease the patient should beat least a FAST 7A along withsecondary conditions

Keys to Scoring with the FAST scale include: Scoring must be sequential: Scoring should reflect the lowest consistent and uninterrupted score Therefore, your documentation should not reflect frequent changes inFAST. i.e. pt FAST 7A one week and 7C the next. The trajectory of Alzheimer’s is always downward, and use of the FASTscale should reflect thisUsing theFAST Scale i.e., Pt should not be a FAST 7C one week and then “go back” to a FAST 7Athe next Unable to ambulate without assistance: This means without personal assistance such as a caregiver holdingthem up so they can walk and does not include use of a walker, cane, orstandby assist Verbal communication: Must be limited to approximately 6 or less intelligible different words inthe course of an average day or an intensive interview Deficits must be a result of the dementing process: Ex. Limitation with walking can not be from osteoarthritis or other nonrelated disease processes.

The New York Heart Association (NYHA) Functional Classificationprovides a way of classifying the extent of heart failure.Using theNYHA Patients with heart failure should fall into 1 of 4 categories basedon: Limitation during physical activity Limitations/Symptoms in regards to normal breathing Degree of SOB and/or Angina

NYHA Functional Classification Class I (Mild) No limitation of physical activity. Ordinary physicalactivity does not cause undue fatigue, palpitation, or dyspnea(shortness of breath)Using theNYHA Class II (Mild) Slight limitation of physical activity. Comfortable atrest, but ordinary physical activity results in fatigue, palpitation, ordyspnea Class III (Moderate) Marked limitation of physical activity.Comfortable at rest, but less than ordinary activity causes fatigue,palpitation, or dyspnea Class IV (Severe) Unable to carry out any physical activity withoutdiscomfort. Symptoms of cardiac insufficiency at rest. If anyphysical is undertaken, discomfort is increased

The Activities of Daily Living (ADLs) Measurement include: Ambulation Continence Transfers Feeding Bathing DressingADLsThe amount of assistance required describe: Independent Uses device Personal assistance – how much (standby, 2 person) Completely dependent (total care, unable to perform any selfcare) Be descriptive! Rather than saying “Dependent in 5 of 6 ADLs,” documentwhat they are: “Standby assistance with ambulation with walker;occasional incontinence; minimal assistance withtransfers; independent in feeding; moderate assistancewith bathing and dressing”

Extremes in nutritional status are associated with increasedmortality, especially in geriatric populations Greater than 10% weight loss over 6 months is associated withhigher mortality in geriatric populations as is a BMI less than 22 Decline in # or % of meals consumed is associated with increasedmortalityNutritionalMeasurements Obtaining nutritional measurements is part of the LCD guidelinesand can help support the patient’s terminal trajectory. Nutritional Measurements include: Weight Mid arm circumference (MAC) Body Mass Index (BMI)

Keys to Nutritional Measurements include: Obtain an accurate actual weight (not reported) whenever possible Use the MAC consistently. Keys to consistency include:NutritionalMeasurements Measure in centimeters Use standard method: Measure the mid point of the posterior upperarm from the acromion (bony prominence of shoulder) to the olecranon(elbow) and mark it. Place the tape around the upper arm, directly overthe mark at the midpoint on the posterior aspect (back) of the upperarm. Keep the tape perpendicular to the shaft of the upper arm. Pullthe tape just snugly enough around the arm to ensure contact with themedial side of the arm and elsewhere. Make sure that the tape is nottoo tight that it causes dimpling of the skin. Obtain a MAC on every patient at admission and with eachsubsequent comprehensive nursing assessment visit.

Now that the why’s and how’s of documentation have beenexplained, let’s look at some examples of nurse’s notes!Documentationof the Nurse’sNote As you read the following notes, think “Are there anyinconsistencies?” “Would I add anything?” “Does thedocumentation support a terminal trajectory?” Remember narrative notes should stand alone and tell acomplete picture. A solid nursing narrative will “paint thepicture” of terminal trajectory by using LCDs and assessmenttools appropriately as well as documenting comparative datawhenever possible.

BACKGROUND: 75YO Female with primary dx of Cerebral Infarction Unspecified“Patient sitting in W/C sleeping and slumped over upon this RN’s arrival with lower lip protruding.Patient did make some verbalizations to this RN today, but these were in her native tongue, didrouse easily to her name, and followed directions appropriately during physical exam, holding outher arm for BP and pulse ox to betaken. Language barrier present, though patient mayunderstand more t