fine printLast year, a hospice medical director in Pennsylvania, was convicted of Medicare fraud for false certifications of the clinical eligibility of patients for hospice care. The wrongdoing involved appears to be fairly black and white.  However, another more nuanced area of regulatory oversight of physicians is looming on the horizon. This is focused on the requirement that the certifying physician has either reviewed the patient’s record, or examined the patient prior to composing the physician narrative for the certification of terminal illness. Claims are currently being disallowed on the basis that evidence is lacking to show that the certifying physician actually reviewed the patient’s record, if that physician did not examine the patient him or herself.

The relevant language, from Subpart B of the Medicare hospice regulations is as follows:

§ 418.22    Certification of terminal illness. 

(b) Content of certification

 (2) Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification as set forth in paragraph (d)(2) of this section. Initially the clinical information may be provided verbally, and must be documented in the medical record and included as part of the hospice’s eligibility assessment.

(3) The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms.

 (iii) The narrative shall include a statement directly above the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient’s medical record, or if applicable, his/her examination of the patient. (emphasis added)

Let’s unpack the italicized portion of the attestation and address how to assure compliance:

  • The certifying physician must compose the narrative, which is a summary statement of the medical information supporting and explaining the physician’s determination of the terminal prognosis, and clinical eligibility, of the patient to be certified.  This is based on information/patient data, which must be documented in the clinical record.
  • The regulations allow for verbal information initially, but are clear that this then needs to be documented in the patient’s record.
  • The physician narrative should contain language that references the findings of the face-to-face (F2F) encounter, if applicable (whether performed by a nurse practitioner, non-certifying physician, or certifying physician).

§  Example: I have reviewed the findings of the nurse practitioner’s F2F encounter of 4/15/2015, which paint the picture of a severely dyspneic, oxygen-dependent patient, limited to bed-to-chair transfers.

  •  The physician narrative should contain language referencing relevant findings of any physician examination of the patient (whether performed by a non-certifying physician, or the certifying physician).
  • Any inconsistencies in the clinical record (e.g., conflicting assessments of the patient’s structural, functional, and/or activity level; FAST, KPS/PPS score; BMI) that might bear on prognosis need to be addressed in the physician narrative.
  • References to the source of supportive information from Interdisciplinary group (IDG) assessments can be included in the narrative.

§  Example:  The team social worker notes of 02/04/2105, state that “ Mrs. S. appears weaker than my last visit 3 weeks ago, and is now bedbound”.

  • The certifying physician can include language from the regulatory mandate within the narrative itself.

§  Example: Mrs. S is an 89-year-old female with cerebral atherosclerosis with the secondary condition of vascular dementia. On my review of the medical record, Mrs. S’s decline is demonstrated by…

  • IDG documentation should reflect all information sharing (verbal and written) with the certifying physician, whether in meetings or through other communication channels (e.g., phone calls, emails).
  • The attendance of the certifying physician at the IDG meeting does not, in itself, satisfy the requirement for review of the patient’s medical record.
  • Physician narratives should include language that evidences medical record review.
  •  If the certifying physician has personally examined the patient, then the letter of the law of the attestation statement has been fulfilled. Best practice would seem to dictate that, even in this case, the medical record should be reviewed and contribute to the decision-making process and narrative composition by the certifying physician.

Remember, the signed attestation is required for technical compliance, but must be supported by evidence within the narrative of review of the medical record, or examination of the patient, by the certifying physician!

If there are any best practice recommendations or experiences you have had that would add to this discussion, please share so all may benefit!

Posted by: Suzanne Karefa-Johnson, MD, Senior Physician Consultant, Weatherbee Resources, Inc.