One component of the hospice certification of terminal illness (CTI) requirements is the narrative summary, a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician. The Center for Medicare and Medicaid Services (CMS) states that the narrative summary must be individualized, include clinical circumstances, and cannot contain check boxes or standard language. The physician’s narrative summary must provide comprehensive medical details to demonstrate justification for hospice level of care.
Hospice clinical documentation compliance reviews often reveal that hospice narrative summaries lack comparative data and are not written in narrative format. Frequently, the documentation is completed with bullet points or phrases, and only indicates the patient’s current medical status. Although medical status may be poor, this type of documentation does not necessarily reflect recent decline or validate terminality.
Because of this, we’ve outlined several tips to help hospice physicians create a quality narrative summary that support the patient’s health status.
1. Start with the basics
The narrative summary should include objective data or metrics, such as height, weight, body mass index, mid-arm circumference, Karnofsky Performance Score (KPS), Palliative Performance Score (PPS), Functional Assessment Staging Scale (FAST), New York Heart Association class (NYHA) and pertinent diagnostic test results.
2. Include the last six months of the patient’s status
It is crucial to include information indicating the patient’s status within the last six months prior to hospice consideration. Symptoms should be documented with degree of severity and include descriptors such as: sharp pain and rating on a scale of 0-10, dyspnea with or without oxygen use, nutritional intake, dysphagia, amount of sleep per day and current and/or recurrent infections, along with any other pertinent diagnoses.
Often, this information is obtained from previous medical records and should be kept on file for support. Documenting previous and current objective information assists in demonstrating a downward disease trajectory and should paint a distinct picture of decline and terminality.
3. Utilize LCD guidelines to support medical necessity for disease-specific and non-disease specific diagnoses
The Hospice Local Coverage Determination (LCD) guidelines provide support in determining hospice medical necessity for disease-specific and non-disease specific diagnoses. Eligibility worksheets are available for Alzheimer’s Disease and related disorders, Amyotrophic Lateral Sclerosis, cancer, heart disease, Human Immunodeficiency Disease, liver disease, pulmonary disease, renal disease, stroke and coma and non-specific diseases.
All worksheets contain data collection sections for non-disease specific details, which include physiologic impairment of functional status demonstrated by KPS and/or PPS less than 70%, dependence on assistance of two or more activities of daily living (ADL) and secondary conditions or co-morbidities. The primary hospice diagnosis determines which worksheet should be selected for baseline disease-specific and medical criteria collection. Additional LCD guideline worksheets can be completed to provide stronger support for terminality. By including the objective data obtained from the LCD worksheets, a strong hospice narrative summary is supported.
The strength of a certification of terminal illness relies on the physician narrative. The hospice physician should provide a strong and effective narrative summary with measurable data. Frequently, a thorough review of clinical records by an external consulting agency can assess for the effectiveness of hospice physician narratives. If found lacking, this inadequacy creates an opportunity for expert education for both the agency, physicians and clinical staff.