All right, well, it looks like we've got a pretty good crowd already here this morning. Looking forward to a good conversation. I'm Bruce Hammond, I serve as HMDCB's Executive Director, and I really appreciate seeing so many familiar faces, familiar names from past coffee chats. It's great to have you here. And for those of you who it's your first time, looking forward to your contributions as well to help your fellow hospice physicians with the issues they're facing and giving you the opportunity to connect with one another. I wanted to just take a few moments before we get started to share just a couple of things with you. First, as you probably noticed that the session is being recorded, we're doing that primarily to be able to send that back out to you afterwards so you can have access to this afterwards. So I just wanted you to be aware of that. And also wanted you to be aware of the fact that we are in the middle of our initial application window. So I'd like to encourage you all to encourage your fellow physicians who are not yet certified to apply this year. We have the application window open through April 26th. The early bird deadline for folks to apply for initial certification is March 22nd. They saved $250 by doing that in late fees. So we certainly want to encourage you to help spread the word about that with your non-certified colleagues. And I'm really excited to introduce today's moderator of the session, Bernice Burkhart. Bernice is a member of HMDCB's board, and she is the chief medical officer at Home Health Foundation just outside Boston. And she'll be kind of helping us maneuver through all of the conversations and the questions that we've gotten prior to the session today, as well as things that come up during the session. So Bernice, I will turn it over to you. Thanks so much to everybody for being here, and look forward to a good conversation today. Well, thank you, and I'm so excited. I've watched a few of the previous chats, and everyone seems so engaged that I'm looking forward to some very stimulating conversation and sharing. So as Bruce mentioned, we do get questions sent in beforehand. And just looking through some of these questions, a lot of them deal with some compliance issues. And Gina and Bruce will talk about that a little bit later with a little heads up on something there. But one of the things that is talked about, and I want to hear if anybody has any thoughts about this, is verbal consents, particularly for enrollment and admission to the inpatient unit during the pandemic, and whether or not anybody saw any allowances for that. I know that sometimes we can get verbal consent, but there's this other piece of it, right? It's the notice of election that also needs to be signed. So I'm curious to hear if anybody has any thoughts about that. And I know I've started off with one of the more challenging questions, but I really wanted to kind of get the juices flowing, if anybody had any thoughts on that. Looking around at the boxes, I don't see anyone unmuting yet. I see a smile, someone looking up, okay. This is Cleo Younger from Cedar Rapids. We didn't do any verbal consents. We were concerned about the regulatory issues with that, so we just had to make a lot of effort to... Okay, we're having a little bit of technical difficulty here. Can you hear me now? Yes. Yes. Okay. Yeah, so we didn't do any verbal consents. We thought from a regulatory standpoint, that probably wasn't going to fly. But then we just had to make heroic efforts to try to get actual things signed. So that meant trying to do different electronic ways to get people to sign stuff. And a lot of times, just going to people's houses in random rural places. But we didn't take the risk on doing verbal consents. I know that for us, sometimes we would send the electronically emailed blanks, right? And then we would go pick them up and have that discussion. So we did take heroic measures. And one of the things, like I said, was the NOE piece as well, that needed to be completed as part of the whole right picture. I see... I'm going to not say this right. No, we aren't. No, we aren't. I just had this issue almost like 10 days ago, and I spent like two hours to search to see if there's any revisions related to like exception during the pandemic. The only revision I saw in October 19, 2021, specifically said they want the signed consent. They did not give any exceptions whatsoever to not sign consent. So I ended up declining the patient until the family were able to... The power of attorney was in Florida. And somehow, I mean, we delayed the admission for one day, but could not find any exception to the regulation. In fact, they did reinforce it in October, 2021, which is during the COVID. COVID. Yep. And how frustrating that is, right? Because what we don't want to do is form any barriers for people to access hospice care. And yet here we have this where family members may be out of the state, and you can't just get that from them. Anybody else have feedback on that from what they're doing or what their compliance or quality teams have told them? Yeah, I thought so. Dr. Wilmes, I know that you came on and it was crowded at the time. Well, thank you for noticing, but I think largely others have addressed. I was weighing in with the challenges we discussed, so I don't think I have anything to add, but thank you. Of course. And it's probably easier just to say Jerry, because it is two syllables and nobody understands how to pronounce it. So Jerry's fine in this group. Thank you. Thank you for that. Okay. So I mean, I think it sounds like what I'm hearing is that most people are trying to get their written consents, period, end of story, and that the CMS clarified that they expected a written consent. So I think we've maybe come to consensus on that one, but I thought it would get everybody chatting. So we're going to move on, because now we go from consents to GIP, because GIP is something that it's always a hot topic, no matter what aspect of it you're looking at. And one of the things that was asked was, in a free-standing inpatient hospice unit, can we use the bed for a routine extended stay with the patient paying for room and board, and even stay for up to one to three months, of course, then being hospice-appropriate? So there's no question about them being hospice-appropriate, and clearly there's no question about them not meeting requirements for inpatient level of care. They need long-term placement, so to speak, or hospice terms of long-term, right, one to three months, and staying in a free-standing inpatient unit under routine level of care. Any thinkers on this topic, because we're going to expand from that to a couple more? I know that some places have beds that are deemed more long-term. I can't think of a word now. Someone will have to help me. I'm having word-finding difficulties this week. I'm trying not to worry about it. But we have, where I am, accepted people for routine level of care, and for one reason or another, whether they couldn't get placed somewhere else, or there were some challenges, they did end up staying, I think, one and a half to two months under routine level of care, paying room and board, and remaining hospice-appropriate at that time. They ultimately transitioned and died on routine level of care in our inpatient unit. Anybody else have that similar experience? Hey, we have a free-standing hospice unit, and oh, about three years ago, we actually transitioned some of our beds to include this residential program. So we keep patients there in this shape or form for as long as they're hospice-appropriate. We find that the room and board cost is probably just right around the same cost as for an assisted living. We take far better care of them. The only problem we've had is sometimes our patients get so much better that we have to transition them. Yes, yes. Interesting graduation problem, right? Thank you, and I'm going to use first names. I don't know the titles, if that's okay. I don't mean to be forward. But yes, residential beds. Thank you. I couldn't think of that. And I know that when I was in Florida, there was another, we had a hospice that we worked together with, and they actually only had residential beds in their facility. They kept patients there long-term as well. But again, most of our beds are GIP. I think we have two that are licensed as residential, so we can allow for that. Anybody else have a similar experience? I see some people that are not muted. I may call on you. Sure. Can I? Okay, so I do have actually, and I'm actually the one who submitted the question. So the problem raised from the administrative standpoint, they, okay, they were afraid of, they came in to tell me, it's a red flag when you keep routine patients for a longer period of time, because we're not long, and so forth, which we know, we're not going to keep them for a longer period of times. However, I spoke, I spoke to the, there is any problem with this, if we're violating any rule. So their answer, again, Ohio Health Department, they said, as long as you don't, okay, as long as you do not prevent GIP patient appropriate to come into your center, because you fill your, your rooms with routine care, you're okay. This is the final answer from them. I did not see anything violate using the inpatient bed for routine care from the CMS. But again, as I have from the administrator, it's a red flag for us. So if anybody has any clarification, we'll appreciate it. I will tell you that we try to limit our routine level of care patients in our inpatient unit to patients who really have a very, very short prognosis, but our routine level of care. And going to a nursing home would be a burden for the family, particularly now with the visiting, well, it's better now, but with the visiting limitations during COVID, families who had someone who, a loved one who had a very limited prognosis, and I'm talking days, right, who needed routine level of care, but could not receive that in their home for whatever reason, they didn't have the supports in the home setting, look to that as an alternative. But we don't do long-term stays under routine level of care. Anybody else on that? Because I think, you know, probably people have different practices in different parts of the country too, right? I don't see anyone unmuting, but I see someone who has like a smile that they're hiding behind. They're like, I think I want to speak, but no, I'm going to hold off. All right. Oh, I see a hand up. Yes. Oh, is that from before? Well, we're going to, I'm going to leave this one open and see if we kind of circle back to it because I think there's probably more to say here, but we'll see. I don't want to cold call anyone just yet. It's a little early in the hour, right? And there is one more question here about GIP and that is, how are people handling a transition? And are they handling a transition? If a patient is on GIP level of care in their inpatient unit, and can they transition that patient to respite level of care after a GIP stay? So they're no longer GIP and, you know, considering transition to respite level of care. I don't think that's allowed, Lily and Planir. I don't think that's allowed. Other voices, I see. Yes. I do believe it's allowed as long as the family or as long as they meet the reason for the respite. Like for example, they came in the GIP and now the patient was like, we face this a lot. Patient was living independently at home, went to the hospital, now hospice GIP, family struggling to find new arrangement for 24 seven care. So they use the five days respite to transition, to have some time to allow them to find new arrangement for their loved one, because the level of care changed from before hospitalization to current situations. So did we use it? We use it a lot. Any other voices on this? Looks like it may be ripe for sharing. I'm sorry, except if the patient came from nursing home long-term, of course, you don't put the respite at that time, but if patient came from home, then you're okay, I believe. So we have had patients in the hospital setting who have been GIP level of care, not in our inpatient unit. They happen to be in a contracted hospital for whatever reason. And the family has been vigil in the hospital. They had been taking care of that patient before their acute hospitalization and having increasing care needs of the patient as their disease rapidly progressed to the point where they were. And when that patient had no longer met GIP level of care, and the hospital didn't have a place for them really anymore, we have, again, based on the needs of the family, it wasn't an automatic, oh, okay, let's give them a few days. This particular family is demonstrating that they have been worn out and need a minute of respite so that they can kind of, again, build up, get respite, get refreshed, and then be able to take over the caregiving for this patient who's no longer GIP level of care. So we don't do it a lot. And every time we do it, we want to make sure that we document pretty well with the circumstances that have led to that different level of care and why, and to try to support it. Anybody else has any kind of similar or different experience? Yes. Charles. Oh, hi. I'm sorry. I'm going to unmute. No, I don't actually. I just wanted to listen to kind of get some aspects of that. Thank you. That's why I'm participating. I haven't encountered a lot of circumstances, but it's similar to the prior conversation is when there's family breakdown and they're in GIP. That's when I try to document whatever's going on in the family and see if I can make a case for respite. And Danielle Godness, it looks like you're unmuted. I don't know if you wanted to add. No? Okay. Yes, Bruce. I'm scanning to see who's unmuting and who's getting ready to say something. The only thing I was going to mention or ask is perhaps we could. I think someone said that they didn't think it was allowed. So perhaps there's somebody that maybe that person could unmute and share why they think that's the case. And perhaps there's a way in which we could help work around that. I don't know. That's just a question. And it sounds like some people are doing it and one person said they didn't think it was allowed. There might be some opportunity to help. That's awesome. Thank you for that. I'm the one who said it. I'm the one who said it. And I was just under the impression that that was the case. My question would be, has Medicare actually or CMS actually said something about it? Is there something written in stone someplace? But it's just, I'm going to say that I was always under the impression. That you couldn't go from G.I.P. to respite. So I would be looking for some direction or some codification of one way or another of that, you know, this issue from CMS. I do think it's a little counterintuitive. And I will say it's respite. If you look at the guidelines on inpatient respite level of care, sometimes it's a little challenging. So for instance, I was challenged here, I was told, oh no, we can't admit someone brand new onto respite level of care. And I couldn't find anything that said yes or no, other than, you know, you have to have all four levels of care and a patient may be admitted to any of these levels of care. So I tried to get that sorted out and brought it up to some different experts that I knew. And they verified for me that you can admit, and this is a little different, but you can admit someone to any level of care. You just have to document to support it. And certainly, we can circle back and try to get some concrete information around it. It's funny how there are some things that they just talk a whole lot about and other things that you just don't get a whole lot of concrete information for, I guess is the best way to put that. But you have not seen anything in CMS or NGS or Palmetto or CGS that explicitly states, no, you cannot do this. Has anyone seen that? No, and on top of that, where is, or if there is guidance on how often someone can be granted respite, right? So some people say, oh, it's once a benefit period. Oh, it's once a month. You know, there really isn't anything written in stone on that either. True, and you know, people get really fierce about it too. They're really adamant. Like, no, it can only be once a month or once a benefit period. And there is nothing that explicitly speaks to it. What I've told my teams is, or the teams that I work with, right, is, you know, certainly if someone requires that respite stay repeatedly and on a frequent basis, then you need to look at, you know, their setting of care. And maybe that's an indicator to you that you need to look at either increased assistance in the home or long-term care placement, right? And that we should use that as a guide, if you will. But I, yeah, you're right. There's nothing that explicitly has a limit on the number of times someone can access that respite level of care. My understanding is that there has to be one day between any respite stays. If they get home and things break down again, then you can actually do, you have to have one day between. And then my understanding is that there is a ratio. You can't have more respite care days than routine days percentage-wise. So I guess you could do some calculations to figure out if your hospice organization as a whole is going over that. But that's my understanding. And I don't know that I've ever seen that in writing. I think we, in the industry, we have a lot of people who are in the hospital and I think we, in the industry, we tend to kind of move towards what makes sense, right? And then things become more, and then we kind of go by them kind of like the whole, you have to have, you can only have respite once a month or something like that, that becomes like accepted truth in agencies and it's not necessarily so. I don't know about the one day in between. I guess that kind of makes sense from a billing perspective but I have not seen that, again, in writing. I've not seen the limitations, just the up to five days. That's what I've seen. And of course, if it's in a contracted facility that you have to have a RN on staff for that timeframe. Those are the two things that I have seen explicitly stated. I'm just reading this. Oh, okay, there's a, in the comments section, there's someone indicating that a patient was admitted Thursday, on a Thursday, GIP. Following day, oxygen saturations were in the 90s and the ALF could not accept her back until the following Monday and the hospice administrator was able to work on her staying in the hospital as a respite stay. Has anybody seen that? I have not seen that. I've seen it in skilled nursing facilities, obviously in freestanding hospice units. Let's see. Okay, I probably can't read this whole thing. There's something in the chat here. They talk about the caps, right, and the period of the cap time. Not sure how many pages this is, but there is a reference in the chat for everyone. It looks easy to read, but I won't take the time to read it right now. I'll be respectful of everybody else's time. All right, we're gonna move on. There was one question that came up in the chat that I think is actually one that is not GIP. I'm sure you're all thrilled, but that does come up quite a bit and it's a question about handling procedures for paracentesis, putting in drains. The question is, do you do it at home at the bedside? Do you discharge a patient to the hospital and then re-admit? And does anyone still do the bedside drains? Input on that from the crowd? Hi, Lillian. We try to send people to an emergency room or a same day type of thing if we need to be. Hello, hello, come in. Hello? Okay, all right, Lillian, we're back. And I see you, we'll get to you too, yep. Okay, so I'll just quickly repeat. We tend to send people to either the emergency room where we've prearranged to have it done or to interventional, outpatient interventional or some same day kind of place and hope and pray that they don't get admitted and bring them back home. All right, and we've got Cleet raising his hand. And then do you cover that? Oh, one second. Yes, we have to get approval from the GM first, but yes. All right, Cleet. Yeah, we use, our IR service at our hospital is usually very accommodating. We can typically get people in within 24 hours to get something drained, but we try to be thoughtful about it. Now, if you're approaching a Friday and somebody is getting close, then you probably need to be thinking about that going into the week. And then we kind of use a, you know, two or three strikes, you know, then maybe we talk about getting a Plorex catheter placed. They require a longer heads up for that though. Usually that's a 48 to 72 hour process to get a Plorex place versus just a drain. And we do the same. We use our local hospital IR. We make an appointment, we set it up. We do cover it. I would be right there, Dr. Allen. And we don't discharge for that and it's, you know, it's related and as it's related, we do cover that. And we just try to contract with our partner hospitals so that we get a decent rate. But other than that, no, we don't discharge. And Allen. Hi again. Yeah, I'd be very, very careful and actually would say, I think you could run into problems if you are discharging people or making them revoke to have a procedure, have something and readmit. That is what's often known in this industry as churning. It is not appropriate. And it is related. Now, it depends what kind of drain you're talking about but things are a lot different these days. Some things are really easy. If you're talking about ascites and it's again, right patient, right person, whatever else and putting something in at home at the bedside for a person to, I'm sorry, for Thoracin, mixing all my words up, to do that type of drain. If you're talking about something that is more involved that you need interventional, again, you can have a one-time contract, whether it's again, with your, you know, endoscopy lab or some other things and you can negotiate that in advance. But I'd be very, very, very, very, very careful about discharging from hospice, having something done and then readmitting. Thank you for that. And thank you for the firmness with that because that is one of those things that is a red flag that we are told about in every education session you can go to. That's why I made a point that we don't discharge because it is related. And we used to have one provider who could, who used to be able to do the paracentesis at the bedside. And these days, it's just, we just send them to IR now. We don't do them at the bedside anymore. We will sometimes send someone in for a pleurex placement if they've had, you know, needed recurrent paracentesis as well. And we do cover that, again, because it's related and it's impacting the plan of care. And it's certainly, hopefully making things more comfortable for the patient and family that they have to go into the hospital each time to get another paracentesis. Anybody else want to, yes. Yeah, hi. You know, so I, my background's in emergency medicine. So we used to do a lot of ultrasounds and do paracentesis in the ER. I'm just wondering, does anybody use like one of those devices at home, ultrasound to do procedures at home? You know, I don't know, I haven't read about it, but I mean, I'm wondering if people are starting to do that. Thank you. If I could, if I could come in, it's Jeff Marsh. Actually, I routinely do my paracentesis at home with a handheld ultrasound. I haven't sent somebody in the eight years I've been at my hospice, I haven't sent anybody to the hospital to do any procedure. My background's in pulmonary critical care. So I've been accustomed to doing this for my whole career, but I find it to be very, you know, certainly very appropriate for the patient. I mean, you know, even, you know, trying to make it easy to have them come into the hospital, it's quite an ordeal to have them transported in, getting the procedure, waiting, you know, before and afterwards, and then transporting back home, you know, to be able to do it, you know, right in the room is obviously quite nice. And, you know, it's also, I think, very cost-effective from the standpoint of my hospice. You know, it's, again, it takes me the time to go over to the house to do that. It takes the procedural costs of the equipment that I have, but we, you know, I'm able to bill for that procedure, so thereby I can, you know, recoup, you know, whatever I'm losing in that way, and we're also not paying for the procedure in the hospital nor the transportation to the hospital. But handheld ultrasounds, I've got a GEV scan that I've been using for the last eight years, and it works fantastic. I mean, I use it for a lot of other things, but it's, you know, it's certainly part of the standard of care for doing paracentesis. I, you know, learned how to do these on the blind, but I would never go back to doing that again. Thank you for that, because my second question, follow-up question was gonna be the use of the ultrasound. That's actually one of the reasons why I discontinued doing it at the bedside. I personally did never get it at the bedside, let me be very clear, but that's one of the reasons why we stopped doing it at our agency at the bedside, because it was being done, you know, the older way, without the use of the ultrasound, handheld ultrasound. And I felt that if you're gonna do it, you should do it with the ultrasound, right? You're saying that's a standard of care, so that's great. All right, how are we billing? How are you able to bill this if it's a related procedure and you're the attending and hospice? Nope, where we just bill it as like you would bill for a home visit for, you know, but we bill the procedure to CMS and we've had no trouble getting reimbursed. And, you know, again, when you do ultrasound, you get a little extra coin for doing it that way as well when you document it. And this is billing for professional services. This is not part of the per diem responsibilities that we have, so yes. Anybody else? Yes? So two other things. If people are gonna do this, remember what we sometimes did, for example, when I was in Florida, there were some people who were comfortable doing so, and we'd bring those patients, for example, at times to our inpatient unit. Not that that's a GIP day, but that would also be something that to schedule, it's easier to get in and out of our unit. We'd have things there. I put in the chat my strong suggestion, anyone interested in doing this and considering, I highly recommend having vacuum bottles. It improves the timing, the comfort, not wondering, okay, am I in the right location, whatever else. The last thing is if you're going to contract, and there are some people who may not be part of your hospice, remember, again, these other services that get billed since it's related and goes through your hospice, you'd need to have that contract beforehand, not after the fact. And unfortunately, a lot of places don't think about that ahead of time and you're in the midst of it, right? And then, but you can develop that for the next time because clearly it's not a one-time deal for most hospices. We all have patients like this that require this kind of intervention. Charles Strulovich, did you have something else to add? I would just make one recommendation or maybe one thought process moving forward. Would there be interest in maybe at AACM having, when it's in person, having maybe a small session on doing ultrasounds as a pre-conference? Because learning like simple paracentesis and just some other common entities is not that difficult. It's pretty a very quick learning curve. So I'm wondering if anybody thought about that, if what people have thoughts about something, doing something like that would be. I would go. I would too. I wonder if that falls under perhaps one of the SIGs. I know that they have surgical SIGs, right? The different special interest groups. Perhaps it would fall under one of those groups. Yeah. We can certainly share that idea with the HPM staff and see if that's something that they, letting them know that this was something that several folks had said that they might be interested in so we can certainly share that with them and move that forward. Thanks. Yeah, thank you. Yes, Donna. Someone mentioned that there are codes for procedures. When I started using the billing for symptom visits that are related, I was told by our billing department that there are no procedure codes in hospice. And unlike in my office where I could have billed for an IND or an injection of a Versa or whatever, and G2 placement for someone who's intractably vomiting, very effective things, but I was told there are no codes for those. So I've just been using the visit code. Is there someone, someplace you can send me to to find those codes? We can certainly see the resources there. One of the questions that, so if anybody knows, please speak up, but I'm gonna transition this to one of the other questions that a couple of coding questions came up as well. And again, I will just say that my understanding is we're allowed to bill for the professional services that we provide, as long as it's not included in the per diem and what's expected of us, right, as in our medical director role. So obviously the face-to-face encounter, you know, IVG meetings, that kind of thing. But the question that was asked about billing was, where is it? It was right here too. The question was about billing, ah, here it is, billing for a patient for, it's a non-hospice doctor seeing a patient for a non-hospice related problem. Can the patient still see that specialist, if you will, that's not related to their hospice diagnosis? I'm really trying to, I'm looking at this and it's just like a bunch of letters and I know what's in here. But that's essentially the gist of it, which was, you know, how do you handle patients who want to see a specialist for something not related to their hospice diagnosis? And I, anybody have anything to share on that? I had a patient with a bad squamous cell cancer who needed an excision for comfort, but she was dying of pancreatic cancer. And she ended up going to see a plastic surgeon. It was not related to her primary illness. That really occurred several months into her stay. And just considered that, you know, they should build their normal code with the, there's a modifier, I believe, for them to do that. And she went to the office. I think the problem comes when they can't go to the office because they're so ill. But I do, my understanding is that we can send patients to specialists if they're not part of the, you have to be careful if it's cardiac and pulmonary because they could try to make them related, but that if it's clearly different, you can do that. You can send them to the- I think they can go, I think they can definitely go to the specialist. I mean, obviously they can just bill for the visit as long as no investigations are done. For any question, you know, even if it's related to their hospice diagnosis, it's if they do any procedures, if they do any diagnostic testing, then that is going to be potentially covered by hospice. in terms of something that's completely separate, I think that depends completely on how, you know, how easily you can separate that away from their hospice diagnosis. I had a patient a number of years ago who was hospice appropriate. I can't remember their primary diagnosis, but she insisted she wanted her cataracts taken out. And she went and she had her cataracts. We did, we kept her on hospice the whole time she had them. I think she died about a month later. I'm not sure she really got much benefit from it, but, but that, you know, we certainly felt was carved out of what her hospice care would have been. So, yes. The one thing I would remind people is there are modifiers out there, and I always, it's a GW and the TV modifiers, but I think of GW, I think of without, right? So the GW is, that's related to the hospice diagnosis. So GW is not related to the hospice diagnosis, the GW is related. So I do bet you can, the problem is a lot of subspecialists, they are, that, however we say, I'm not sure they are educated enough about choosing the GW, the GW is not related to the hospice diagnosis, which the bill does not go through. But as far as I can tell and verify that you can, you can go to specialists and then a specialist, actually, even like, okay, let this, the, if it's not related to the hospice diagnosis, then the modifier GW, if related to the hospice diagnosis, then the GW. Like this has happened, for example, somebody with the lung cancer, and they still like to see their oncologist, the oncologist, not the attending physician. So they're going to go just to hear about their lung cancer, it is hospice related, but I am the attending physician as, so they go, they have to use the GW in this case, the oncologist. Yes, Donna, thank you. Have them use, sign an ABN then, before they go, because it was my understanding that you couldn't use those specialists unless they were the attending of record for the certification from, you know, the attending that's certifying the visit and caring for them in the hospice. I'm sorry, I think I may have missed the lead into that question, and I was paying attention. My understanding is that you cannot send someone to anyone for a related illness unless they are the attending of that hospice stay. You know, the person's private attending for that hospice stay has to be the only person that can bill them, is my understanding. There may be a couple things that are overlapping here, and sorry, I'm not able to type as fast in the chat to keep up with everyone, but what I was going to mention, number one, there is a hospice medical director certification board sponsored upcoming or aligned activity for coding and billing. Gina kindly put the link in there. I'm not connected with it, so I'm not plugging any conflict of interest. Lauren Templeton, people that were on some prior chats may recognize her, so she's an expert in this and is going to be having that coding and billing. The other thing I want to emphasize that some people may be blurring a distinction is that when we talk about whether or not someone can submit a bill for a visit, if it is related, it has to be submitted through the hospice in the Part A. So one of the things that gets misunderstood when they say, oh, our claim got denied, I put the modifier in, well, two things. Number one, if they're not the attending of record, any doctor seeing a hospice patient for a related condition, you have to have that contract in advance, okay? You can't have it after the fact and catch up. That will be non-billable, so if you don't follow the rules, it's not billable. Next, if they go see them, and again, this is where the hospice has to agree on the plan of care, you have the contract there, then they have to submit their billing through the hospice, and it's called pass-through. If you're not doing the process correctly, it gets denied. If you don't have the right codes and modifiers, it gets denied. If the hospice does not have this contractual relationship established prior to the service, then you're not in compliance, and, you know, I'll defer. I saw that earlier, Ron Krosnow was on, and he's much more knowledgeable on this than myself, but there are some distinctions that just because something didn't work in one setting or with one way does not mean that is generalizable for not working. The last thing, if I can, careful when you say it's not related to the hospice diagnosis. In 2010, CMS changed the regulations, hospice conditions of participation with one word. Anything related, they changed diagnosis to prognosis. Those of us that are under Palmetto as a fiscal intermediary, they've been very aggressive to say anything is related. If you have a hospice patient for cardiac on service, and they fall, break a hip, and need to be pinned, they consider that related because that debility and other things is tied into the prognosis. This is a much bigger issue than we can solve here, and, of course, they didn't ask us, but these are the regulations. I just want to give people a heads up so you aren't painting a bullseye on you. Thank you for that. Yes, I agree. The contracted relationship with the provider who's giving a specific service that if you have been able to identify something as not related to the prognosis, which I know everything is related, but you do have to have that contracted relationship for that to pass through. Otherwise, they won't get paid, and then at least all kinds of issues in relationships. I will say that one of the questions was, does anyone know of any refresher courses for billing? I will second that. Lauren Templeton is giving a talk, and the registration link, Gina, was kind enough to put in the chat, so please do check that out and look for mailings. I'm sure we advertise, right? Yes. Yes. Okay. It's 1249. I know that we want to talk about some upcoming things. I just wanted to look and see if there's a question here that I'm not sure I understand. It says, how to effectively manage expectations limiting MD participation and patient chart review and admissions. It almost sounds as if they're trying to limit the hospital's medical director from participating in chart review and admissions. I don't face that problem. I get asked to look at things all the time. I don't think the author of the question is online right now. I don't know. No? Okay. So I didn't quite understand that. How to handle pediatric patients who have acute care providers, but family wants hospice MD to overlap slash supervise their decisions. Anybody on that? I think that would hold true for anybody. I know we get a little bit concerned, especially when it's pediatrics, because they're not just little humans. It's a different field. So any input on that? Yes. Go. Go ahead. Sorry. In Illinois, we have one of the largest pediatric palliative care and hospice programs. So some of the things I think without getting too involved here, you may want to build those bridges with your pediatric colleagues and think about curbsiding or even more formally saying up as a, you know, assistant medical director for pediatrics, if you're getting more pediatric cases. And that'll also help in your program and exposure, building those things. What I've used for pediatricians who are not active in hospice and palliative, the UNIPAC series is good. At one point, I had hired a academic, you know, chair of the pediatrics department who had been in the role 14 years and was alive. I'm sorry, was in medicine longer than I had been alive at that point. And yet he was shocked at how different the approach for pediatric, you know, hospice and palliative care is. There's also a very, very active, one of the best special interest groups through the academy is in pediatrics. You'll find a lot of mentors and others to participate. And CAPC is now doing a lot more that, again, there's also blurring with the legislation, more pediatrics are entitled to dual eligibility. So they can pursue simultaneous hospice and palliative. And that may be a different mindset than your organization's ready for, but definitely check with the academy. Thank you for that. And yes, we always try to engage the pediatrician and work collaboratively with them and try to establish a relationship there. And that gives confidence in the family and support to the pediatrician and support to your staff who are not used to pediatrics, if they aren't. And then there was one question that had, it was, how do you, so what is the plan of care with patients admitted with TPN? And I guess that could be a whole nother hour. Maybe I should have started with that one. I'm sorry. Can you guys hear me now? Yes. Yes, we can. Hi, my name is Vincent Morilla. I'm the only hospice medical director board certified in Puerto Rico. I'm working in Puerto Rico, in San Luis. So I'm trying to build a palliative care and stuff in Puerto Rico. So it's been hard. Just let me start quickly. Like in Puerto Rico, the hospice gets paid a less rate in the state compared when I was doing my training. So I just got the position now and I encountered some question about patient being discharged with TPN from the hospital. Um, it's very hard to cover, uh, to be honest that the medication is very difficult for the hospice. I am not working in the biggest hospice in Puerto Rico. I am working in a hospice that is trying to do the best they can and building the palliative care. Uh, so we were really trying and I, um, and I met with the owner and I said, you know what, we can do this better. So, um, um, questions like from the hospital, the patient have a small bowel obstruction. I mean, malignant obstruction. They always send a patient on TPN and your hospice candidate, you guys take care of that. Okay. Um, do we actually plan that you guys plan ahead with the family? Like, Hey, you know what, we're going to try these for, I don't know, a week, two weeks. Uh, that's something that I think Kelly could be done. You know what I mean? Like, um, um, now is a patient goes home with TPN. Now stopping the TPN is going to be very hard for the family because they think that we might be killing them or starving to death. So, uh, I'm, I'm, I'm getting patients like that. So what should I do in this case? Like, I mean, but what is your advice? I'm sure a lot of people will be jumping in. I will just a quick, I know, I know it's late, just at least that's something quick. So I can, you know, it's a conversation that starts with the admission assessment nurse. Um, when she goes into evaluate the patient for hospice eligibility, oftentimes that conversation is happening about the ongoing appropriateness of that intervention, you know, especially for patients, um, who, uh, maybe have fluid overload, for instance, um, or have some other, uh, reason that it may not be the best, uh, solution for them at that time. So certainly one of the things we look at is whether or not that intervention remains appropriate for the patient. And if not, then we, you know, clinically appropriate, then we try to give them the end of life circumstance and that, and, um, you know, the move towards a more palliative approach to, to care. So we try to have those conversations and that's an ongoing dialogue, uh, certainly, um, but you and your organization have to decide what you're going to, you know, take care of. And thank you, Bruce, Dave Bassett, you put your email in the chat so that we can follow up with you. And then there was a recommendation to think of, um, Clinimix, um, IV fluids with amino acid, which is more cost-effective and better tolerated than PR, than TPN. Um, so that's in the chat, um, as well as a recommendation. Um, and yes, the full TPN with lipids is, as they were saying, can make people very uncomfortable. And that's one of the things that, you know, again, we really try to come at, what are the goals for this patient? The goals are, you know, not to prolong suffering or not to cause any further suffering. Um, or, you know, then we try to frame everything within that lens so that, um, decisions then make sense. And, and I know it's hard to walk away from, you're killing them. Uh, but, uh, you know, we, we need to try to reframe. So to help people understand what, what that medication is actually doing, um, and, and treatment, because it is an intervention in the treatment. It's not food. Um, and I think we also need to be careful about how we talk about things. Um, so it is 1258. Go ahead. Who had something to say? We'll take it. I just find that culturally in the Northeast, anyway, I have found that patients from Puerto Rico, their families are incredibly resistant to stopping any kind of treatment. And I think you have your hands full. Um, we, we actually don't do keep can have a small hospice. It's only home care. And we have decided that in order to be able to stay afloat, we just can't afford to do it. But, um, it's also fraught with that difficult cessation. We, we do sometimes take them on a G tube feeding, but that's a little bit easier to discuss stopping when they start having problems or vomiting. Um, but I think with TPN, it becomes much more difficult than I have to say that I, I really have empathy because of what, what we've experienced culturally. Okay. Now that you can't try, but I, but I think it's, it's a lot different than the other patients that I see of other cultures in terms of talking about stopping. I don't know if anyone else has, has noticed that, but when I've talked to, um, our chaplain is from Puerto Rico and he said, you're never going to change that. That's their whole, it is like murdering. Yeah, exactly. That's the way it's seen. You know, I did my training in, in, in St. Louis and I work also in Kansas. It's a very different, I'm from Puerto Rico, born and raised here. So yeah, it is much different than when I trained, I've been living in the state for years. So, so, um, and I think there are a couple of things to begin from that one different cultural approaches, right. Um, to our, just the wide variety of patients that we have, that's one. Um, and two, knowing that we have this wonderful resource of colleagues that are getting together to be able to have these conversations, to share their experiences, knowing that no one individual here is the expert, right. Um, we are the experts in our field, uh, and we're, you know, hospice medical director certified, um, but that we can share and then move forward with any of the, um, questions and, you know, all of this connection, uh, which is fabulous. And with that, I'll hand it to Bruce. Thank you very much, Bernice. Just really quickly as we close here, um, for the purpose of the recording, uh, Dr. Bonilla's email address is d r v b o n i l l a at gmail.com. I don't think the chat actually is, um, comes with the recording of the video. So I just want to make sure if someone listens to this later and has thoughts, they can share that with Dr. Bonilla. Um, I also just wanted to say very quickly as we close, um, a quick reminder that tonight, uh, if you are a Twitter user, uh, some of you are, I can see some faces on here that are Twitter users. Um, if you are, there is, um, the monthly HAP hashtag HAPC chat, uh, at 9 p.m. Eastern 9 p.m. Eastern it starts. So, um, utilize the, the, um, hashtag, um, HAPC chat, and, uh, you should be able to, um, connect with other folks who are, um, in that, uh, in that group. And then lastly, um, we are going to, I'd like just to encourage people to sign up for future coffee chats. We have those coming up. Gina, I think is going to share a slide here really quickly on the screen that provides some of those upcoming dates, as well as, um, we have an upcoming, uh, some upcoming webinars and, um, the, um, uh, the upcoming Hospice Physician Compliance Conference, which, um, is something that we partner, uh, with Weatherby Resources to create. Um, and, um, it, it's a really good and really comprehensive look at, uh, compliance issues. So, uh, I encourage you to take a look at that as well. All HMDCs receive a 15% discount code for that registration fee. So you can reach out to Gina to get that gparisi at hmdcb.org. So again, thanks for a really vibrant chat today. Thanks for everybody for participating. And, uh, we look forward to seeing you, uh, again, sometime soon. Bernice, thanks so much for moderating. Really appreciate it. My pleasure. Thank you all. Thanks everyone. Have a good day.

hospice care

verbal consent

GIP level of care

specialist visits

pediatric patients

written consent

ultrasound procedures

coding and billing

TPN

palliative approach