Webinar Recording: Reducing Regulatory Risk

Strong Documentation Protects More Than Compliance

Hospice organizations provide exceptional care every day. Yet in today’s regulatory environment, the quality of care alone is not enough to protect against claim denials, ADRs, TPE reviews, and other forms of medical review. Documentation must clearly demonstrate terminal prognosis, support continued eligibility, and tell a consistent patient story across the interdisciplinary team.

As scrutiny around hospice eligibility continues to increase, many organizations are asking the same questions: What are auditors looking for? How do we document decline effectively? How do we reduce regulatory risk without creating additional burden for clinicians?

This webinar addresses those challenges directly. In this session, Armine Khudanyan, CEO of QAPIplus, and Natalie Venable, Founder of Thrive Healthcare Solutions, share practical strategies for strengthening hospice documentation, improving eligibility support, and protecting revenue integrity. Drawing from their experience in quality, compliance, survey readiness, and medical review preparation, they walk through common documentation gaps, documentation frameworks, and real-world examples that organizations can implement immediately.

Whether your organization is preparing for increased medical review activity, looking to reduce audit risk, or simply wants to improve the consistency and quality of clinical documentation, this session provides actionable guidance to help build a stronger, more defensible hospice record.

What You’ll Take Away

• How to document hospice eligibility more effectively at admission and recertification
• Common documentation gaps that lead to claim denials and audit findings
• Strategies for documenting decline across different disease trajectories
• How to align physician narratives, CTIs, visit notes, and IDT documentation
• Best practices for reducing ADR, TPE, and medical review risk
• Practical frameworks for creating more objective, measurable, and defensible documentation
• Ways to strengthen revenue integrity while supporting high-quality patient care

WEBINAR TRANSCRIPT:

Denise Stanford

All right, hello and welcome everyone. Thank you for joining us today for a very timely topic. First, I'm going to cover a couple of logistic items. We will be sharing the slide deck with you in a PDF format. in the Q&A. If you have any questions for the presenter during the topic today, please use the Q&A to post your questions there. We'll review those, and as the time allows, we'll post those questions to our presenters at the end of the session. Also, everyone joining us today or that registered and was not able to join will get an email. with an automatic notification that the recording is available to review. So if you get that from us, that is a legitimate link to the recording.

We'll also post this on our YouTube channel for anyone who can register today that wants to be able to review the content. And with that, I will introduce that we have two guest presenters here today. They are going to be presenting on the topic of reducing regulatory risk, clinical documentation for hospice eligibility and revenue integrity. And we're very happy to have Armine Khudanyan here today from QAPIplus, and Natalie Venable joining from Thrive Health Solutions. I'm going to turn it over to you.

Armine Khudanyan

Thank you so much, everyone, and thank you for joining us, and thank you for the overwhelming response to this webinar. My name is Armine Khudanyan. I'm the CEO of QAPIplus. I'm a nurse by background, and most of my experience is in home health and hospice post-acute care. And my specialty is in quality compliance, survey preparedness, patient safety. So clinical documentation is the, I think, the cornerstone of all things quality and compliance. So I'm very excited to join Natalie for this webinar. Thank you.

Natalie Venable

All right, thanks, Armine. I am also delighted to be here and again, also very just thrilled at the response to this webinar. My name is Natalie Venable. I'm the founder of Thrive Healthcare Solutions. I am an occupational therapist by trade, CHAP certified consultant. My space really focuses on regulatory compliance, survey readiness, quality outcomes, everything related to hospice, OASIS accuracy in both the home health and hospice industry. And so we're excited to be here to talk about a very timely topic. As we go through. There's going to be times when Armine and I kind of chat back and forth with each other as we bring our own experiences and thoughts into the conversation. But we welcome your questions.

We also want you to know that there were a lot of questions submitted with the registration, and we're going to try to address some of those as we go through the presentation today. So We're going to talk about why documentation is under scrutiny right now, and why so much this year. Common documentation gaps that are driving denials and audit risk. How do you identify those up front to help mitigate that? So what are those auditors looking for? And when we say auditors, we're talking about those medical review auditors. at the MAC level, how to document decline and document defensively to give yourself credit for the work that you're doing, creating consistent interdisciplinary patient stories.

So Armine is going to hit on that later on the tail end. And then practical strategies. to reduce regulatory risk. So tools and strategies that you can take back with you to help protect your agency. So let's talk about why this topic matters right now. There is increased focus on hospice eligibility, and the purpose really is preventing and identifying fraud, but also protecting patients and protecting the agencies that are doing. good works and that have good intentions. We're seeing increased medical review, increased claim denials, recruitment. And if you're here today, it's probably because you work for a hospice agency, you support a hospice agency, whether you're, you could be EMR, you could be a consultant, a software program, but you care.

You care about the space that you're in, that we're in together, and we want to be doing the right things, and oftentimes We can lose sight that the goal is to provide excellent, high quality care, but our documentation has really got to support that. And under medical review, the question's not just about whether appropriate care was provided, it's whether the record clearly proves that the patient was eligible. that the plan of care matched the patient's condition, that the services that were billed supported the terminal prognosis. And so we want, as we go in, there's some clarity that we want to bring to this conversation.

And one of those things is that we're talking about, when we're looking at medical review, We're looking at conditions of payment. And that's not to be confused with conditions of participation. So conditions of payment is what those medical reviewers are going to be looking at. conditions of participation, compliance with State Operations Manual, that's going to be survey readiness. And so Armine and I hear often, well, I did really good with my survey. I should be fine, right? And those aren't apples to apples. There is some overlap, but they're not the same things. Two different sets of regulations. Armine, do you have anything you want to add there?

Armine Khudanyan

Sure. I often hear whenever an organization has an ADR to submit to a MAC, I often hear that, you know, this clinical record just went through survey. We did great with it. There were no findings. So I'm very shocked that the ADR was denied. So just

Natalie Venable

Thanks.

Armine Khudanyan

It'll be great to tune in on the difference between conditions of participation, which is what an accrediting organization would most likely look at, versus conditions of payment, which is what the MACs would look at per regulatory compliance.

Natalie Venable

Yeah, so you may be saying, what are the conditions of payment? And so one of the first places we want to guide you is to Medicare Benefit Policy Manual, Chapter 9. And that's going to outline your conditions of payment. And so there's a pretty big document. It's got a lot of information in there. Today, we're going to be talking about a piece of what's in that policy. And that piece is specific to clinical documentation. So we're going to look at reducing regulatory and reimbursement risk specific to how your clinicians document throughout the journey of their hospice care. And we're going to look again, what are those auditors looking at?

Where does documentation break down and how do we create a consistent, measurable, defensible documentation that paints a story? Remember, your reviewers don't see the patients. They only see the record and the record needs to paint the picture. The goal is not to increase burden here, documentation and burden. We don't want to contribute to caregiver burnout or clinician burnout. We don't want to document more for the sake of volume, but we do need to document better. We need to be more intentional about what we are documenting. And that means connecting the diagnosis, the terminal diagnosis to decline, to functional status, to symptom burden and management, comorbidities, goals of care, interventions.

And everybody that's involved, that whole IDT team needs to be painting the same picture, but just through a different lens of their disciplines. And oftentimes that we don't see that happening. It looks like everybody's looking at a different patient. There's a lot of misalignment there. In today's regulatory environment, I'm sure that everybody's heard about the six month that we're in, again, identifying fraud, protecting patients. We've got things like provisional period of enhanced oversight or the PPEO program. We're seeing more ADRs, more TPEs, more SMRCs and UPIC audits. which are all different types of audits that are looking at compliance with those conditions of payments. There is a heightened focus on documentation.

And so not just about, you know, with the election of benefit completed or did it have the right date or do we get the face-to-face done. But specifically, what's happening in those visit notes that supports that terminal prognosis? And again, focuses on the conditions of payment, not necessarily conditions of participation. And I just want to throw this out there. You know the cadence of being surveyed, right? You don't necessarily know if or when you'll be selected for medical review. And I would say it's safer to just assume you're going to get selected for a medical review one type or the other. Just be prepared.

And when you proactively prepare, and I think Armine can vouch for me here, It is a wonderful return on investment because the time, the effort, the resources that it takes to appeal denied claims can be significant and those claim denials can really be detrimental to an agency. So. Keep in mind, Medicare Benefit Policy Manual, Chapter 9. That's what we're going to be speaking from today. The other thing I want to mention is there's a lot of focus on long length of stay. So 180 days or more as long length of stay. Also a lot of focus on live discharges. So if you've got high occurrences of that, you might be at risk for being selected. for medical review.

There are a lot of technical denials that can be that can be that can cause claim denials. And typically when you have a technical denial, that can kind of, unfortunately, the whole claim will get denied regardless of how good the documentation was. And we're not going to talk about all of those today. So election of benefits, face to face, CTIs, signature requirements, addendums, all of those are areas that could lead to a claim denial. But we're going to focus on documentation specifically. I personally, when I worked with agencies who are going through medical review, Documentation is a trend. Just across the board, the documentation is lacking. And hospice providers often think of documentation as a clinical survey compliance task. It's all of those things.

It's heavily tied to revenue integrity. And if you've never been through claim review, this may be a new space for you. But the hospice claim. is only as strong as the record that is behind it. So a hospice agency may provide excellent care, but if the chart does not clearly support that care and support the terminal prognosis, the medical necessity, the level of care that's being provided, that's not supported by the IDT, documentation, you could face a denial. You could face recoupment, and that could lead to delayed cash flow. The burden of appealing takes time. It is not a quick process. You may have to seek out attorney support, which is also costly when it comes to the ALJ level of appeal.

And so the focus, the proactive focus up front is really going to help you ensure that if you are selected, you've got a better chance of. no claim denials, or if you do get a claim denial, at least you're going to have a lot to work with when you appeal that claim. CMS and the MACs. So when we say MACs, we're talking about Medicare Administrative Contractors. And so depending on where you are across the country, you may have a different MAC. I'm in Texas. Our MAC here is Palmetto. But they review those claims against a standard. And we're going to talk about what some of those standards are in a bit.

But they're looking at the patient's prognosis, which should be a life expectancy of six months or less if the terminal illness runs its normal course. So in a nutshell, documentation needs to support that prognosis. And we know that different diagnoses have different trajectories. And we're going to talk about that in a bit of how How do you document against a disease that declines really slowly versus one that declines really rapidly? What does that look like? So the takeaway here really is the cost of week documentation can be really, really significant. And the care that is not documented clearly is not going to be defensible. And just because we did well with survey does not mean our documentation is defensible.

So we look at what MACs are denying right now. And we've got several questions from our audience around election of benefits, CTIs, face-to-face for supporting payment, avoiding ADR findings, medical review. That's going to be a piece of your building a strong record. And we're going to talk about, Armine is going to talk about in a little bit, kind of a front end to back end charting and where those pieces fall in, because they certainly are important. And if you're missing pieces of those that can result in technical denial, and oftentimes when you have those, as I mentioned before, the entire claim will be denied. But if you've got all of those pieces squared away, then it's really going to be heavily weighing on your documentation.

And we're seeing a lot of denials by the MAC. So we put some examples up here from Palmetto, CGS, and NGS related to some of the trends. If you go to your MAC website, you'll see the claim denials trended either for the previous year or the previous quarters. And you'll be able to see exactly what they're looking at. And some of it is highly avoidable. And I think the number one for Palmetto right now is you just didn't submit the documentation. And so just submit the documentation. You've got a chance at potentially avoiding that claim denial.

It's important to understand that not all MACs approach hospice review exactly the same way. Most rely heavily on the hospice Local Coverage Determinations or LCDs for determining terminal status. And so if you go to your MACs website, you can locate those. And essentially, it's a standard or guide on how to identify objective data that aligns with that terminal prognosis. You may hear the LCDs called it the UniPolicy. Other MACs put greater emphasis on disease specific criteria. So regardless of which one you're under, the goal is still the same. Documentation has to support the prognosis. The LCDs speak heavily to evidence of decline, but it's not a hospice regulatory requirement. The regulatory requirement is that documentation needs to support the terminal prognosis. Thanks, Chelsey. Okay.

Key themes across all MACs. So you'll see here, we've got, we've just pulled out some things. And this is kind of a deeper dive. So we're taking it in a deeper level from just documentation, does it support terminal prognosis? So no objective evidence supporting. decline. Physician narratives lack specificity. I'm just going to go ahead and add or they're copy pasted from the nurse's notes. Documentation does not align with LCD criteria. Documentation does not clearly support terminal prognosis. Inconsistent interdisciplinary documentation. I mentioned it looks like each team member is describing a different patient. And that doesn't bode well under medical review. Imagine your review, you never laid eyes on this patient and all. All the notes look different.

Insufficient support for continued eligibility, so recertifying patients when maybe it's not really appropriate, repetitive or cloned charting, so copy pasting, lack of measurable progression over time. These are all predictable patterns, which means they're also preventable. And that's why we're here today, to give you tools and resources that you can take back and implement quickly and easily to see that quick change, behavior change in how you're documenting is going to protect you as you move forward. One of the questions we had from the audience was how can hospices ensure election of benefits, NOEs, CTIs, face-to-face, addendums, support payment, avoid common ADR findings and claim denials?

Again, we're not going to go into all of those things today, but what we want you to know is That chapter 9 benefit policy is a great resource for you to reference. When Armine talks about the front end to the back end, we'll kind of talk about some of those pieces. But that initial intake to admission piece, along with that initial comprehensive assessment, that is going to build your foundation. And from there, if that foundation is solid and your documentation subsequent to that is consistent, you're going to have a good case to build upon. But those pieces are key because if any of these little pieces are missing or they're incomplete, that could jeopardize your claim.

Okay, so the core regulatory standard is the six month terminal prognosis. We talked through that. So the central question in hospice eligibility is, does the documentation support that the patient has a life expectancy of six months or less if the terminal illness runs its normal course? So we know the physician certification is required. But the certification alone is not enough. The rest of the record needs to support it. The medical record should contain enough clinical factors, objective information, descriptive notes to show that the terminal illness is progressing in a way that would reasonably support the physician's conclusion. So there's got to be alignment there. MACs state that hospice records should show enough clinical factors and descriptive notes to demonstrate that progression.

So the key is not simply just stating the patient is declining. The key is how are they declining compared to what they sign. Where were they? Where are they now? Why hospice? Why now? And then do you have anything observable or measurable that you can plug in to really support that? And. thought process. We had a question here that was, how can admission nurses stay ahead of evolving regulatory requirements while ensuring eligibility documentation supports hospice admission and reimbursement? And in working with hospice agencies and whether the nurse is Been around for a while, or maybe they're new to hospice. I think there's so much value in taking the time to thoroughly train those admission nurses. It's crucial.

keeping them updated on the regulatory requirements such that they understand the why and the impact. What is the why behind a complete election? Why am I asking you specifically to make sure this date is input here and that it's complete and that there's a signature here. And that if they say they want that Notice of Non-Covered Items, that we get that to them within this amount of time. All of those pieces are really important because they tie back to conditions of payment. So taking the time to thoroughly train them is first. But then I also think providing resources. I've seen a lot of agencies that will use LCD pocket guides.

So decreasing that burden of memorizing all of that disease specific criteria, LCD guides, that they can just kind of, oh, my terminal illness here is congestive heart failure or Alzheimer's. What are my, what are the things I'm looking for here that's going to help build this case? And then when they go in to do those recertifications or reassessments, keeping that theme, that prognosis threaded through what we're doing. So there's a consistent comparison back to that baseline. And we're thinking about where is the patient now compared to where they were. And then lastly, I would say mentorship. Being in the field myself, it brought a lot of value and was very comforting to me to have a mentor. Hospice is not easy. It can be difficult.

And on top of that, you're dealing with death and dying, and that can be heavy. And so I think there's a lot of value to bringing mentorship. Armine, do you have anything you would want to share on that from your experience?

Armine Khudanyan

No, it's everything is great. One thing I would say about spending the time and the resources to provide that front end training to clinicians is very important because often when an organization has an ADR or has a survey, The first question I always hear is, do you know, can you make a referral to an individual who can review, who's an expert in ADR and who can review? And that question is always interesting for me because I almost want to let the organizations know is that the best The best investment you can make is turning your admission clinicians into ADR experts, basically.

And teaching them, giving them the tools to document it from the front end, making sure you have all the required documentation, making sure you're capturing all of those nuances.

Natalie Venable

Yeah.

Armine Khudanyan

Because nurses capture the nuances, it's just, it's in the care, but it never gets translated into the actual documentation because it's never about patient care. Clinicians provide great patient care. That's why organizations get so hurt when ADRs are denied because they took such great care of the patient. But just linking that care into.

Natalie Venable

Yeah.

Armine Khudanyan

The translation of the documentation is very important.

Natalie Venable

Yeah. Thank you for that. I agree completely. And when you said, you know, agencies get surprised because they provide great care and I have experienced that, you know, they've said, well, this patient passed away. I don't understand. And it's the documentation. It has to be there. It's not enough to say, well, we provided excellent care or the patient passed away. Your documentation's got to paint the picture of how you got there. All right, so LCD alignment matters. So we're going to talk about the LCDs, so the Local Coverage Determinations. And again, you can go to your MAC and you can see specifically how your MAC performs hospice review. And again, some of them may focus more specifically towards disease specific criteria.

We're going to look at the LCDs. So again, Local Coverage Determinations, Medicare guidelines that outline clinical criteria and documentation that's expected to be seen. So that's what your MAC is going to use for the most part to look at your documentation for that alignment. Again, good care alone is not enough. So weak documentation is going to use vague generalized language, lacks measurable findings, fails to show progression, does not support the terminal prognosis. Strong documentation is going to be more objective. It's going to demonstrate measurable decline over time. It's going to connect symptoms to the terminal diagnosis. and support continued eligibility clearly and consistently. So the LCDs help you establish a strong baseline.

So I can't say this enough, go to your MAC website and look to see, are they using LCDs? Are they using disease specific criteria? What is yours using? And then you need to go study that. And how is your documentation aligning up with how your MAC is going to review your documentation? The admission nurse should be strong here. Also, just want to mention briefly, Age does not make someone terminal. And so we've been asked, you know, is there LCD guidelines for old age, just normal aging? No, not to my knowledge. So just because your patients in their 90s or 100 does not mean they're going to pass away in six months. So we need billable, appropriate terminal diagnoses.

One of the questions that we got from the audience was how can hospices confidently support eligibility in complex clinical situations while aligning documentation with LCD guidance? Strengthening physician narratives and reducing ADR TPE and claim denial risks. I think as a whole, this presentation is going to kind of address that question. As far as complex situation, I think that's kind of loaded as far as what that means. But I think holistically looking at the patient as an IDT team is a missing component. And it's not just about what the nurse documents. It's about the physician and it's about the rest of the team. And the entire team builds the case.

And you can build a really strong case, or you can have a team that's Doesn't build a strong case where one. Team member or core team member is devaluing what the other one said because it doesn't match or align. I can't tell you how many times I've seen a nurse narrative that says the PPS is 50 and the fast is 7E and the physician narrative says something totally different. How do you How do I go in for an appeal on that? It's tricky. So there's got to be alignment. So if you can get alignment among your team, that's going to help you maneuver those situations and have a better chance reducing ADR and claim denial risk.

So let's talk about one LCD in particular, just to give an example. So if we look at congestive heart failure.

To support hospice eligibility for end-stage CHF, documentation should demonstrate both of the following. One, severe congestive heart failure with significant symptoms at rest or with minimal exertion. And if you dive into some of those LCDs, you're going to see things like New York Heart Association Class IV. You're going to see things like ejection fraction of less than or equal to 20%, but is not required. You're going to see specifics of, here's some ways to demonstrate that. Number 2, optimal treatment or patient no longer responsive to treatment. So we've done all the things. Nothing's working anymore. I'm not going to be treated for this. And then some supporting factors that may include declining PPS or KPS, increasing ADL dependence, weight loss, dyspnea, so on.

If you look at the LCD, you're going to see even more specifics. history of unexplained syncope, history of cardiac arrest, brain embolisms of cardiac origin, and so on. So there's a lot of specifics there that you can reference. And oftentimes those specifics are there with your patient. We're just not capturing it and putting it into the record. Let's look at a documentation example. So, for weak documentation. Chelsey, can you advance the slide, please? Thank you. At weak documentation, we've got patient fatigue, short of breath continues to decline., and then we've got strong.

Class IV CHF symptoms with dyspnea at rest, oxygen saturation of 86 on room air, despite optimal med management, patient requires assistance with five or six ADLs, no longer able to ambulate independently due to fatigue, weakness, PPS declined from 50 to 40% over the past two benefit periods. Increased sleeping for 12 to 18 hours daily with an 8 pound weight loss over six weeks. Escalation of symptom management required, including initiation of morphine for dyspnea. Now, as I read that, you saw you envisioned a patient likely. When I read the first one, you couldn't envision anything because there wasn't anything there that's descriptive, right? One of these is not like the other. One of these paints a picture.

I want you to keep that in mind when you think about what happens during medical review. A picture is being painted, and that picture needs to align with the terminal prognosis. And so we put some examples here of why this documentation fails, why it works. And I think that, you know, at this point, you guys are kind of picking up where we're going with this. No align to function, no objective clinical data, does not support LCD. This could be fatigue, short breath, that could be specific to COPD. That could be specific to anything. This one is very specific to CHF.

It's easy to tie back the symptoms here, the objective data back to congestive heart failure, and it's I, you know, I can't argue that there's solid appropriateness for hospice. There is eligibility in this. And there's a question that we'll get to later on, but it says, you know, how do we make sure we're writing enough, but not too much? How do we make sure we're not increasing the clinician? It shouldn't be a burden to write this sentence here, these sentences here on the strong documentation side. I think it's about four or five sentences. And over here we've got two. At the beginning, I mentioned being intentional about what you do. We didn't write a book.

We were just very intentional about how we used those four or five sentences. And there's a lot of impact in what we chose to talk about. And that's where you can demonstrate defensible documentation. is being intentional, but that's where that understanding up front comes from. What is my terminal illness? What is my criteria I'm looking at? And how do I build my baseline that I can continue to build upon? So the questions the auditors are trying to answer, as you probably figured out, why hospice, why now? What is the terminal condition? What objective evidence supports decline? Does the IDT tell the same story? And does the documentation support what was billed? So we miss often a lot of things. We miss recurrent infections.

We miss reduced oral intake. We missed increased sleeping. We miss increased assistance required with ADLs. We miss wound measurements. We miss intake percentages, oxygen saturations. We miss things like, oh, patients started with no pain, they have no pain now. But then when we start to dig, what we realize is the patient truly started with no pain. Then they started to experience pain. And then we implemented some symptom management strategies to get that pain under control. And then they started using a PRN meds to manage the pain because it was a breakthrough. And then we adjusted it and the pain is managed, but we didn't give ourselves credit for it. That Hospice. That's defensible documentation.

You have to give yourself credit for the work that you're doing to manage symptoms. So saying things like pains managed is not going to give you credit for that. Common gaps that we see, um, we've got several here. We're going to talk through each of these in a little bit more detail. One of the questions that we got is what documentation practices best support hospice eligibility, survey readiness, and compliance while reducing audit and documentation risk? And I'm going to take it back to that initial comprehensive assessment. When you do a complete thorough initial comprehensive assessment or your documentation shows support of that terminal prognosis. you're going to build a foundation for a really strong plan of care.

And a strong plan of care drafts compliance for both eligibility and your survey readiness. So again, I'm just going to take it back, back to the beginning. And that again, that goes back to having really good processes in place, but also making sure your admission nurses really understand the why and the impact of that first visit. Let's look at gap one, which is vague decline language. So we've kind of talked about this already when we looked at our LCD guidelines, vague, patients declining, poor appetite, weak, continue hospice. That's not painting a picture for your reviewer. You want to give specifics like Eating approximately 75% of meals two months ago. Now they're down to 25 to 50% this week. Weights decrease from 132 to 124.

Spending 18 to 20 hours per day in bed with increased fatigue. This is measurable. It's specific. We've got time frames, impact on function. The example on the right is not a lot of documentation. Again, just there's intention behind the words that were chosen. It's just three sentences. So I think when we ask our clinicians, hey, we're asking you to document more, we're really not asking for that much more. We're asking them to do what we've learned in school, right? which is demonstrate what we have done that requires the skills of a clinician or the skills of that core team member that's going in and not just anybody. There's a reason we're billing hospice for this.

One of our questions was how can hospice organizations prepare for audit. Document slow decline effectively and support continued eligibility without contributing to clinician burnout. And again, I'm going to take it back to, we're not going to ask them to write books. We're just going to ask for intentional documentation. And I think if you can take this back and give some examples, that may help to kind of alleviate some of that stress. Gap 2, no baseline or comparison. We want to tie back to that comprehensive assessment. What objective data did we ask for and how are we progressing against that? So keep that. I talked about threading that. through, reference that every visit that you can, what has changed and tying it back for comparison.

Be careful to give yourself credit where credit is due. Gap 3, physician narrative does not match the chart. I already kind of got ahead of myself on this one. We got some questions about making sure the physician writes a stronger narrative. The nurse's assessment should support the physician narrative, should support the CTI. Specifically, what objective data supports the terminal prognosis? So think about those specific LCDs or disease specific criteria that we discussed. What evidence is there? What's missing? So the physician's going to say, here's what I think the terminal illness is. And I don't, I think it's if it progresses in a reasonable time frame, six months, and then that nurse's documentation should support that.

We need to get away from copy pasting the nurse's narrative. That is not the intent behind the physician narrative. And if you go look at chapter 9, you're going to see guidance around what they're looking for there in a little bit more detail. Gap 4, IDT notes are repetitive but not meaningful. Oftentimes we see a lot of copy pasting, multiple IDT meetings in a row, no change. However, when we look at the visit notes, we see lots of change, lots of things happening. Things that demonstrate decline, things that demonstrate hospice is appropriate that the patient eligible, but the team is siloed. There's no cohesiveness.

And that's really when you've got cohesiveness and you've got the same picture being painted just from a different lens of those members, core members, you're going to have a much better record to defend. And not only that, but that's a part of conditions of participation, so coordinating care appropriately, that's going to help you defend the record under survey as well. Lastly, we have gap 5, which is plan of care does not reflect current needs. And so again, does this sound familiar? Because it might sound like something your surveyor would say. Yeah, there's alignment here between what your MAC is looking for and conditions of participation. So survey readiness for our current plan of care. That's how important it is.

So initial comprehensive assessment helps you build that solid plan of care. And I'll reiterate, when there are no silos and the team works together, the plan of care will stay updated. It will reflect what the patient needs, what's happening to serve that patient. by that team. And you're going to have, again, a more defensible chart to present to your MAC or to appeal. And it also helps you with survey readiness, so you can kind of tackle two things there. All right, so I'm going to pass it over to Armine now to talk about the documentation chain.

Armine Khudanyan

Thank you so much, Natalie. So I am going to share a few concepts with you guys that you can have as a takeaway and a few frameworks I like to teach and talk about when it comes to clinical documentation that can help provide a guide to the comprehensive nature of the medical record. This chain that we've provided is a guide where you can use as an organization to help you go through each step from referral intake to admission to certification, care planning, and of the ongoing visit notes, IDT, research, billing, and medical review. So you can take this chain and use it as a guide where, for example, straight from intake, it's important to collect all of the documents that state what changed.

what record supports the terminal diagnosis. Oftentimes, you'll notice that the diagnosis the patient has during hospice, the patient hasn't had any kind of history with it, any historical treatment, historical labs. So all of that, the H&P, that strong documentation for that clinician to set the initial baseline documentation. So use this chain, answer the questions, and it can provide a real great guide for each. Step of the process. Next, I want to introduce the concept of hospice prognostication. So this is a framework where you can take all of the hospice terminal diagnosis and basically divide it into three, divide it into three groups based on the trajectory and based on the level of decline.

So, going from, we'll go to the first one, which will be for a rapid decline trajectory. So, a rapid decline trajectory includes a group of diagnosis that is the cancer and the oncology type of diagnosis. This is important because these types of diagnosis often follow a rapid decline model. So a patient may appear relatively stable or even normal, if you will, at baseline, but they can experience a very sudden and significant deterioration within days or weeks. So these are the patients where documenting disease progression is important, documenting pain management is important.

For example, one of the pitfalls in documentation for this type of trajectory is documenting that the pain is well managed, pain level is 0, and failing to document what it takes to manage that pain. Failing to say, for example, the patient's pain is 0 because they have taken at least three doses of PRN opiates, let's say. Or now, as compared to last week, now the patient requires around the clock pain management, like a fentanyl patch, in addition to the PRN medications. So just documenting that the pain is well managed doesn't paint the picture. of a patient who will have rapid decline.

One of the questions we had was about a patient who had, I believe it was pancreatic cancer, who had a denial in ADR because within the first 30 days, the documentation did not support the diagnosis. So keep in mind that with this type of rapid decline. This is where you want to be very, very good about documenting towards the baseline of what is different today compared to when they were first diagnosed with this terminal diagnosis. The next set of diagnosis we're going to talk about follow a sawtooth decline. And this includes all of the diagnosis, for example, that have to do with organ failure. So this is all of your COPDs. This is all of the heart failures. kidney, liver.

So any of the organ failures, the reason we expect a sawtooth type of a trajectory is because the body will compensate and decompensate. So as the body is going between compensation and decompensation, you will see this kind of stabilization decline, stabilization decline. So it's very important to admit a patient with organ failure who is at the end stage because, for example, COPD and CHF, these are chronic illnesses. So you would have to differentiate between what is a chronic condition versus when is this chronic condition a terminal condition. And typically that happens when the body can no longer compensate.

So that's the timeframe that you want to admit a patient with organ failure and really heavily document all the recurrent exacerbations or the progressive dyspnea, the reduced activity. activity tolerance, worsening edema. So you want to make sure that all of those are captured and how the patient is no longer able to recover fully from it. This was one of the questions that we had from the audience is how should you document eligibility when comes to these failures. And just keep in mind that organ failure, the patient is always at risk for an MI or a CVA or an event, but that doesn't necessarily mean that it's a terminal illness. So it's the compensation that we want to capture. Next slide, please.

If we can go to the slow decline. So the slow decline in prognostication, this is where the Alzheimer's types of diseases, dementia and Alzheimer's. And this is probably one of the hardest ones to document. and to capture because it is, it does, the projected decline does happen very slow and over time. So it's important to really capture and we'll have some examples coming up of how you capture the specific decline compared to their baseline. So we had a lot of questions for this about when to discharge a patient, when a patient is ready to be discharged, how do you safely discharge an Alzheimer's patient. And about the different types of kind of different documentation requirements for the different types of the disease.

Because dementia itself is not a terminal diagnosis, so you have to be very careful in documenting that type of decline. For example, if it's Alzheimer's disease, that's a more neurodegenerative disease characterized by progressive cognitive loss. So you would have your fast score, the memory loss progression, the sleeping more, social withdrawal, the speaking in fewer words. So that is all of the types of documentation you may have. there versus a more vascular type of dementia where you would focus on any kind of, this would be more of like a stepwise decline that could be, that could come from a patient who has experienced some kind of a vascular event, a stroke, a TIA, and they have not fully recovered from it.

So you may talk about neurological deficits, there may be hemiparesis, contractures, increased falls, declining endurance over time. So again, the theme would be declining over time. So all of the different types, all of these different types of trajectories would have their own types of documentation. So you want to make sure the decline your document. is connected to your terminal list. With this, I'm going to introduce a documentation framework. called the Clear Documentation Framework, which is a great resource. And we've also put this resource in the downloadable sections, where I think can be shared with all of you after. Where using this model, you can document the condition. So what is the terminal condition?

And do keep in mind that the primary diagnosis is not enough to paint a good picture for the patient's decline. So you want to make sure you have the primary diagnosis, the secondary diagnosis, all of the comorbidities that really can relate to these. to the disease burden that the patient feels. Next is you would document all of the losses. What has the patient lost over time? So whether it's weight loss, it's functional loss, and you want to be very specific and have a timeframe of in what amount of time did the patient lose this, whether there is skin integrity decline, respiratory decline. So with the L, you can think of all of the losses. The E is for evidence. So what measurable evidence can support?

This includes weights, MAC measurements, all of your PPS, FAST, NYHA, wound measurements, very important. Documenting the progression and use of oxygen is a very measurable evidence, like they required 2 liters, you know, PRN versus now they're on 3 liters continuous. So that is evidence of measurable decline. Alignment, Ace for alignment. Does the whole chart tell the same story? This is really important and we'll talk more about it during the IDT slide. And also risk reduction. What are some of those documentation risks? that are evident in the record. And a lot of the risks come from not having that clear painted picture. So we have a lot of examples here, documentation examples with appetite and weight loss.

For the sake of time, I won't go through each one of them one by one, but I have them here for you guys to look at. And to know that the greatest takeaway from all of these examples is that it's not just about documenting that something is happening, but it's about documenting how much compared, like how much is happening, what is happening, and how does it compare to How does it compare to their baseline and to their past? So with hospice care, IDT consistency is one of the most important parts of building one patient story.

And just as a reminder, that the social workers, chaplains, this was also another large part of questions that came through, that hospice services are core services and team and it's a team service. So chaplains, social workers, everyone has their role in the IDT. So as clinicians, and sometimes even more important, because a lot of times already the physiological parts are terminal already, it's at the end of life, and patients really need the chaplain, the social worker, to come in and to ensure that psychosocial care is provided, that spiritual care is provided, And just to decline this type of care, I would urge all organizations to maybe let the patients know that they will receive a call from the chaplain and the social worker.

And then once they're able to introduce themselves as a team, then they can, if they still want to decline the service, they can decline it to them. But it's important for the IDT to create one story and from IDT to IDT to have summary of the patient's current status, to identify what has changed from the last IDT, and to keep in mind that the hospice care plan is basically every two weeks this care plan is changing and every time the IDT meets, it's an update to the plan of care. And so with that, we'll discuss a little bit about red flags that can trigger denials in medical review.

So long length of stay greater than 180 days or greater than 270 days without clear documentation of decline. over-reliance on the cut and paste documentation or documentation that does not really apply to the patient, or that can be one of the things I hear the most is if you were to kind of cover the diagnosis in the patient's name, you wouldn't know which patient the documentation was for. So really having specific documentation for the patient, for the level of care. If the patient is receiving GIP level of care, if the patient is receiving, if the patient is receiving continuous care or respite level of care, that the documentation matches.

And one concept that I really want to leave you with is in care planning is when this care planning starts really initially. So when an admission nurse is first meeting with a patient, I call it a three-tiered care plan where you can set the expectation and this also leads to a smooth transition should the patient need to be distributed. discharge so that you can explain to them that, you know, one of three things is going to happen. You may see an improvement, at which point you may need to be discharged to either a home health or to a different level of care. You may experience stabilization.

which would mean that you would need to be discharged from hospice services with the appropriate community resources, and then you may experience decline. And that decline would be the end of life, and you would talk to them about what would you expect about, you know, what are your wishes for hospitalization? Should that day come, are you going to want to go to the hospital or do you want to experience that end of life at home? Or does it need to be in a different setting? And I think the more you plan right from the beginning with the patient and the family, the easier the conversation becomes later when a patient needs to be discharged.

One of the hardest things in discharging hospice patients is when they really need the service. You can tell, and this is why you always hear the patient passes away days after a discharge from a hospice. Because really patients do sometimes get better in hospice because they're such, you know, taken care of so well. But just in that beginning, if you set the tone that if there is no, let's say if there is no decline, because this is where revenue integrity comes in. Once a claim, once a hospice claim is submitted, this documentation needs to be connected with the revenue. Can we go to the next slide, please, Chelsey?

So in supporting this claim, it is important to have those conversations with the family so that this, whether the next level of care, whether it's a discharge or its end of life, these talks can happen right from the beginning. So you are not introducing discharge at the end and kind of surprising or upsetting the patient or the family. So for revenue integrity, hospice documentation has the most impact on making sure that the claims that are billed. So just because this is the point I want to make, just because a claim is submitted does not mean it needs to it's going to be paid or needs to be paid, right? That claim needs to match all of the all of the requirements for payment.

And it can also help support cash flow. It can decrease revenue. And I think a lot of organizations have seen the impact of suspensions, the impact of overpayment requests that the impact it can have on an organization, which can really be. Great. So some strategies to reduce regulatory risk, again, some of the takeaways would be to standardize documentation, to educate clinicians on defensible documentation practices. So really to stay away from vague language, from just general descriptive language. And to really, when chart audits are done, to really proactively link it back to your QAPI program, do performance improvement projects. This was another large part of the questions were about. performance improvement and how to incorporate some of these issues into the QAPI program.

That's what the QAPI program is for. So any of these documentation trends that you are noticing in your organization, it's great to, once you see a trend, once you see a gap, It's great to bring it up to your IDT team, to your clinical educators, to your compliance officers, and really provide focused training. So then one by one, you can take one gap at a time and close it, which will really strengthen the organization. And with that, we're going to go into final takeaways. So to make sure that, to understand that good care alone is not enough, so documentation must clearly support the hospice eligibility, should be defensible, and proactive preparation really protects revenue integrity.

And a lot of the a lot of the one final takeaway before passing it to Natalie for her final takeaway, I would say is that really, really approach hospice care in the manner where the patient and the family are the patient. So it's not just a focus on the patient, it's the entire family. And you're going in to provide this care as a team. So the entire IDT team should be involved in the decision making. The physicians focus their documentation on their medical part. So it shouldn't be kind of a regurgitation of the nurse's assessment. It should really be medically or the medical defensible documentation that the patient has six months or less to live. And And for the clinical team, interventions are important.

So everything that is found, every issue, every need that's there, the IDT should have a care plan for and should have interventions for. And I will pass it on to Natalie.

Natalie Venable

Thanks. I'll make it quick. I just want to take a moment to say thank you. If you're here, it's because you care. And so thank you to you for what you're doing. Thank you to your teams. We know there's a lot going on, focused on getting, you know, the people who aren't doing things right, the bad people. You guys are trying to do things right. And we know that we know there's good intention. And so we're here to support you and we want to empower you. You're providing great care. Now we just got to get that documentation piece and alignment. It's totally doable. And it's a good return on investment.

We, you know, we've kind of shared the the weight and the burden of when it goes sideways. And so just encouragement, keep doing what you're doing. Make sure you're painting the picture. Give yourself credit. Thank you.

Armine Khudanyan

Thank you.

Denise Stanford

Awesome. Thank you both. Just really quick in closing, I just want to reiterate that we will publish the recording of this. If you registered, you'll get an automatic email. Before you sign off today, go into the Q&A and click on the slides and the downloadable resource. Make sure you have access to those. Those are amazing resources and we really want to thank our presenters today for their time in preparing this and also in getting those resources developed for you all. I'm going to do one quick plug.

If you are your sales rep or if you have a sales rep, we are doing a webinar on Thursday to help navigate the conversation around fraud in hospice and talk to your referral sources about that objection and how to demonstrate that you're not one of the bad actors and that you want to take good care of your patients. So make sure you're prepared for those conversations and a good way to do that is to join this webinar on Thursday. There's a link to that in the Q&A as well. And I'm sorry we didn't get to the questions. I will download those questions and we will do our best to address them.

For those of you that posted them, thank you for taking the time to post your questionnaire. There was so much good information here. We just couldn't get to them individually, but we will. do a report and try to address them as we are able to. Thank you, everyone. Have a great rest of your day. We appreciate your time.