CMS Re-Specifies Hospice Visits in Last Days of Life Measure

The Centers for Medicare & Medicaid (CMS) has re-specified the Hospice Visits When Death is Imminent (HVWDII) measure. The re-specified measure, Hospice Visits in Last Days of Life (HVLDL), and was announced by CMS via the report Hospice Visits When Death is Imminent: Measure Validity Testing Summary and Re-Specifications (posted in September, 2020). HVLDL is a claims-based measure that  indicates the hospice provider’s proportion of patients who have received visits from a registered nurse or medical social worker (non-telephonically) on at least two out of the final three days of the patient’s life.  Hospices have had questions about the measure including calculation details and impact on Care Compare and future hospice submission requirements. 

NAHC is consolidating some of the history on the change to the HVLDL, the questions many hospices have and responses in this article, and providing links to previous NAHC Report articles and other resources for the HVLDL. 

Because CMS will utilize hospice claims for this measure, Section O of the HIS-Discharge record is no longer needed.  This is the section that captured the hospice visit data.  Therefore, CMS revised the HIS record to reflect the elimination of this section and updated the HIS Manual.  The final HIS Manual V3.00 is available as is the updated HIS-Admission (updated to reflect current reporting year) and HIS-Discharge documents. The HIS Manual V3.00 is effective as of February 16, 2021 and the HVLDL is effective with admissions and discharges 1/1/2021 and later. 

As reported previously, hospices may use and submit either V2.00 or V3.00 of the HIS-Discharge record for admissions and discharges on or after this date.  Both are accepted by the ASAP system at this time.  If V2.00 is submitted by a hospice, the ASAP system will not capture the visit information in Section O (CMS has stated it is not able to collect data it is not using).  Some hospices have decided to continue using this version of the HIS-Discharge for their own internal visit data analysis and have not reported any problems with submission.  CMS has not given a date as to when the ASAP system will no longer accept  HIS-Discharge V2.00.  

Below are some of the most frequently asked questions about the elimination of Section O from the HIS-Discharge and the HVLDL measure.

Q:  Will CMS eliminate the requirement that hospices submit the HIS-Discharge record as the information captured from it can be captured from hospice claims? 

A:  As recently as the April 13, 2021 CMS Home Health, Hospice, and Durable Medical Equipment (DME) Open Door Forum (ODF), CMS indicated it does not have any plans to eliminate submission of the HIS-Discharge as it is used to calculate other measures.  Providers should note that the Hospice Outcome & Patient Evaluation (HOPE) instrument is expected to replace the HIS eventually.  CMS indicated in the FY2022 hospice proposed rule that the draft HOPE has undergone cognitive and pilot testing, and will undergo field testing to establish reliability, validity and feasibility of the assessment instrument. CMS anticipates proposing the HOPE in future rulemaking after testing is complete.

Q: When will CMS start reporting the HVLDL on Care Compare?

A: In the FY2022 hospice proposed rule CMS is proposing to begin public reporting of the HVLDL no earlier than May 2022 using FY2021 claims data.  

Q: How are the visits calculated in the HVLDL? 

A: HVLDL indicates the hospice provider’s proportion of patients who have received visits from a registered nurse or medical social worker (non-telephonically) on at least two out of the final three days of the patient’s life. While all patient visits are meaningful, only patients with visits on two different days during the last three days of life will count towards the numerator for this measure. These visits can be made by the nurse, the social worker, or both.  So a visit from a nurse and a social worker on the same does not satisfy the HVLDL criteria.

Q:  How  are the last three days of life calculated in the HVLDL? 

A: The calculation of the last three days remains unchanged from the last three days documented in Section O. Information defining the last three days can be found on page 2O-3 in HIS Manual V2.01.  Specifically these three days are “indicated by the day of death, the day prior to death, and two days prior to death.” 

  • The day of death is the same as the date provided in A0270, Discharge Date. (or the day of death) 
    • One day prior to death is calculated as A0270 minus 1. 
  • Two days prior to death is calculated as A0270 minus 2.

Therefore, the day of death is considered as one of the last three days of life in this calculation as it was with the HVWDII measure. Please note that this level of detail is not found in HIS Manual V3.00 because Section O was removed, and the HQRP QM Manual is current as of January 2019 and has not yet been updated.  

Q:  Are any patients excluded from the HVLDL calculation?

A:  The patients excluded from this measure are the same as those excluded from measure 1 of the HVWDII measure pair per the HQRP QM Manual V3.00 (2019).  These are:

  • Patients who did not expire in hospice care 
  • Patients who received any continuous home care, respite care or general inpatient care in the final 3 days of life 
  • Patients whose length of stay is not 3 days (confirmed by CMS in an Open Door Forum on 4/13/2021)

Previous NAHC Report Articles