How to Prevent Hospice Claim Denials Related to Continuous Care Hours

Providers must submit documentation to provide clear evidence that the continuous care is being provided during a period of crisis.

• A period of crisis is defined as a time in which the beneficiary requires predominately nursing care in order to achieve palliation or management of acute medical symptoms
• For continuous care to be covered, care must be provided for a minimum of eight hours during a 24-hour day which begins and ends at midnight
• The documentation should reflect the care provided was predominately nursing care by either a registered nurse (RN) or licensed practical nurse (LPN), which means at least half of the hours of care were provided by an RN or LPN
• The documentation should include the number of hours of care provided by each discipline and it should match the number of units of continuous care hours billed
• Care by a home health aide and/or homemaker may not be discounted or provided at no charge in order to qualify for continuous home care. The care provided by all members of the interdisciplinary and/or home health team must be documented in the medical record regardless of whether that care does or does not compute into continuous home care. Deconstructing what is provided in order to meet payment rules is not allowed.
• While in the majority of situations, one individual would provide continuous care during any given hour, there may be circumstances where the patient's needs require direct interventions by more than one covered discipline resulting in an overlapping of hours between the nurse and the home health aide. In these circumstances, the overlapping hours would be counted separately. The hospice would need to ensure that these direct patient care services are clearly documented and are reasonable and necessary.

Ensure the documentation for all hours billed is submitted. Documentation submitted for review should illustrate the following:

• The services provided, hour by hour and day by day;
• The beneficiary’s medical condition; and
• All disciplines providing the continuous care

More Information

• CMS Internet-Only Manuals (IOMs), Pub 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40.2.1
• CMS Internet-Only Manuals (IOMs), Pub 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.1