Level of Care Tip Sheet MANAGING CONTINUOUS HOME CARE FOR SYMPTOM MANAGEMENT TIPS FOR PROVIDERS WHAT IS CONTINUOUS HOME CARE?

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MANAGING CONTINUOUS HOME CARE FOR SYMPTOM MANAGEMENT

T

IPS FOR

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ROVIDERS

W

HAT IS

C

ONTINUOUS

H

OME

C

ARE

?

Continuous home care (CHC) is one of the four levels of hospice care in the Medicare Hospice Benefit and required by the Medicare hospice regulations. The regulatory definition of continuous home care is meant to include nursing care, covered on a continuous basis for as much as 24 hours a day to achieve palliation and management of acute medical symptoms. Either homemaker or hospice aide services or both may be covered on a 24-hour continuous basis during periods of crisis, but the care must be predominantly nursing care. Continuous home care is only furnished during brief periods of crisis as described in Sec. 418.204(a) and only as necessary to maintain the terminally ill patient at home. (CMS, 2009)

That said, a continuous home care (CHC) day is a day in which an individual who has elected to receive hospice care is not in an inpatient facility and receives hospice care consisting predominantly of nursing care on a continuous basis at home. Hospice aide or homemaker services may also be provided on a continuous basis to supplement the nursing care.

WHAT STAFF CAN PROVIDE CHC?

• Predominately nursing care provided by an RN, an LPN, or an LVN employed by the hospice. • Services provided by a nurse practitioner that, in the absence of a nurse practitioner, would be

performed by an RN, LPN, or LVN, are nursing services.

• Homemaker or hospice aide services to supplement the nursing care.

CONTRACTING FOR CONTINUOUS CARE

One of the major challenges hospices face in providing this level of care is having an adequate number of staff available when continuous care is needed. Added to the challenge is the fact that nursing care is considered a hospice core service. Hospice core services must be provided by hospice employees. Consequently, hospices are not allowed to routinely contract with nurses to provide continuous care. A hospice may, however, enter into arrangements with another hospice program or other entity for the provision of core services in extraordinary, exigent, or other non-routine circumstances. An

extraordinary circumstance generally would be a short-term temporary event that was unanticipated. Examples of such circumstances might include unanticipated periods of high patient loads, caused by an unexpected increase in the number of patients requiring continuous care simultaneously or temporary staffing shortages due to illness. The hospice that contracts for services must maintain professional

Level of Care Tip Sheet

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management responsibility for all services provided under arrangement or contract at all times and in all settings. Regulations at Section 418.100(e) discuss the professional management responsibilities of the hospice for services provided under arrangement.

o Hospices must maintain evidence of the extraordinary circumstances that required them to contract for the core services and comply with the following:

 The hospice must assure that contracted staff is providing care that is consistent with the hospice philosophy and the patient's plan of care and must actively participate in the coordination of all aspects of the patient’s hospice care, and  Hospices may not routinely contract for a specific level of care (e.g., continuous

care) or during specific hours of care (e.g., evenings and week-ends). (CMS, 2010)

W

HEN IS

CHC

A

PPROPRIATE

?

Continuous home care may be provided only during a period of crisis. A period of crisis is defined by the Centers for Medicare and Medicaid Services (CMS) as a period in which a patient requires continuous care, which is primarily nursing care, to achieve palliation or management of acute medical symptoms. If a patient’s caregiver has been providing a skilled level of care for the patient and the caregiver is

unwilling or unable to continue providing care, this may precipitate a period of crisis because the skills of a nurse may be needed to replace the services that had been provided by the caregiver. (CMS, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance, 2011)

CMS has provided examples of circumstances that may qualify as CHC. This list is not all-inclusive nor does it indicate that if a patient presents with similar situations, that it would require CHC.

1. Frequent medication adjustment to control symptoms/collapse of family support system

Situation A: The patient has had a central venous catheter inserted to provide access for continuous

Fentanyl drip for pain control and for the administration of antiemetic medication to control continuous nausea and vomiting. The nurse spends 2 hours teaching the family members how to administer IV medications. She returns in the evening for 1 hour. The hospice aide provides 3 hours of care. The nurse spends 2 hours phoning physicians, ordering medications, documenting and revising the plan of care.

Determination: Despite 8 hours of service, this does not constitute CHC since 2 of the 8 hours were

not activities related to direct patient care. Time spent on documentation and other non-patient care activities are not counted in the computation.

Situation B: The patient experiences new onset seizures. He continues to have episodes of vomiting.

The nurse remains with the patient for 4 hours (10 AM – 2 PM) until the seizures cease. During that time she provides skilled care and family teaching. The patient’s wife states she is unable to provide any more care for her husband. A hospice aide is assigned to the patient for monitoring for 24 hours, beginning at 2:00 PM, with a total of 8 hours of direct care in the first day. The nurse returns intermittently for a total of an additional 5 hours to administer medications, assess the patient and to relieve the aide for breaks. The social worker provides 3 hours of services to work with the patient’s wife in identifying alternative methods to care for the patient.

Determination: This qualifies as a continuous home care day. This constitutes a medical crisis,

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custodial care and the medical crisis resolved within a short time frame, this situation would not have qualified as CHC.

2. Symptom management/rapid deterioration/imminent death

Situation A: 77-year-old patient with lung cancer whose caregiver is 80 years old. The caregiver has

been caring for this patient for 4 months and is now exhausted and scared. The care provided consists of assisting with bathing, assisting the patient to ambulate, preparing meals, housekeeping and administering oral medications. Since the patient is dyspneic at rest, she requires assistance in all ADLs, which equates to 9 hours of assistance within a 24-hour period.

Determination: This would not qualify as CHC since there is little nursing care that requires a nurse.

The patient would however be a candidate for an inpatient respite level of care. (CMS, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance, 2011)

Situation B: The patient’s condition deteriorates. The patient now has circumoral cyanosis,

respiratory rate of 44 and labored with intermittent episodes of apnea. The nurse performs a complete assessment and teaches the caregiver on methods to make the patient comfortable. The nurse returns twice within the 24-hour period to assess the patient. She revises the plan of care after conferring with the patient’s attending physician and with the hospice physician. The

homemaker and hospice aide are sent to assist the caregiver. Within the 24-hour period, the direct care provided by the nurse equates to 3 hours, homemaker with 2 hours, and hospice aide of 6 hours.

Determination: Since only 3 of the 11 hours were skilled care requiring the services of a nurse, this

would not constitute CHC. In this situation, the care required is not predominantly nursing but are comprised of services provided by a hospice aide. In addition, it would not be correct to discount any portion of the hospice aide’s hours or to provide these services gratis in order to qualify for the CHC benefit. (CMS, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance, 2011)

Situation C: The next day, the patient’s condition deteriorates further. She has increased periods of

apnea and air hunger. In addition she is experiencing continuous vomiting and increasing pain. Her blood pressure is beginning to decrease and her respirations are increasing. The nurse remains at the patient’s bedside for 4 hours while attempting to control her pain and symptoms. The hospice aide provides care during 1 hour of this period. The nurse leaves and the hospice aide remains at the bedside for 3 hours. The social worker comes and talks with the caregiver and remains for 1 hour. The nurse returns while the aide leaves. The nurse remains with the patient for 2 hours until she dies. The social worker returns and stays with the caregiver for 1 hour until the mortuary arrives.

Determination: The nurse provided 6 hours of direct skilled nursing care; the aide provided 4 hours

of direct care resulting in a total of 10 hours of registered nurse and hospice aide care. Since at least 6 of the 10 hours were direct nursing care, and since nursing care was the predominant service provided during the 10 hours, the care meets the criteria for CHC. In addition, since the nurse and the aide provided direct care for the patient simultaneously, it would be appropriate to bill for each resulting in a total of 10 billable hours. The patient received 12 hours of care. The 2 hours for the social worker are not counted towards the CHC hours. (CMS, Chapter 9, 2011)

W

HEN IS

CHC

NOT

A

PPROPRIATE

?

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• For a patient who is imminently dying with no acute skilled pain or symptom management needs. • For caregiver breakdown with no acute skilled pain or symptom management needs. (As stated

above, if a patient’s caregiver has been providing a skilled level of care for the patient and the caregiver is unwilling or unable to continue providing care, this may precipitate a period of crisis because the skills of a nurse may be needed to replace the services that had been provided by the caregiver.)

• Continuous home care is not intended to be used as respite care.

• For safety concerns (for example, falls, wandering, etc.) in the absence of a need for skilled interventions.

• As an alternative to paid caregivers or placement in another setting.

W

HERE

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AN

CHC

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E

P

ROVIDED

?

CHC can be provided in the place where a patient resides. CHC can be provided in: • A private residence

• An Assisted Living Facility

• A long term care facility (if the patient is not receiving a skilled level of care, i.e. Medicare Part A skilled benefit)

• A hospice facility if the patient is not receiving a general inpatient level of care

Note: Continuous home care is not paid during an acute hospital stay, in a skilled nursing facility or

inpatient hospice facility stay. It can be provided to a patient in a a long term care facility, where the patient is receiving “Nursing Facility” level care. (CMS, Chapter 11, 2010)

H

OW

S

HOULD THE

IDT

D

OCUMENT

CHC

L

EVEL OF

C

ARE

?

Medicare’s requirements for coverage of CHC are that at least 8 hours of primarily nursing care are needed in order to manage an acute medical crisis as necessary to maintain the individual at home. When a hospice determines that a patient meets the requirements for CHC, documentation must be available to support the requirement that the services provided were reasonable and necessary and were in compliance with an established plan of care in order to meet a particular crisis situation. This would include the appropriate documentation of the situation and the need for continuous care services consistent with the plan of care.

Documentation should include the following: • Reason for continuous care

• Vital signs (as appropriate)

• Observations of the patient’s condition

• Interventions used to achieve palliation of physical or emotional symptoms • Services provided to the patient

• Medications given and the patient’s response • Treatments completed and the patient’s response • Contacts made to the hospice and/or attending physician • New or changed orders received

• Family response to care (as indicated)

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C

OMPUTATION OF

CHC

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OURS

The following circumstances must be met in order to qualify and bill for CHC billing:

• The hospice must provide a minimum of 8 hours of care during a 24-hour day, which begins and ends at midnight.

• This care need not be continuous, e.g., 4 hours could be provided in the morning and another 4 hours in the evening. But a need for an aggregate of 8 hours of primarily nursing care is required. • This means that greater than 50% of the hours of care must be provided by an RN, LPN, or LVN. • When fewer than 8 hours of care are provided, the services are reimbursed as a routine home care

day rather than as continuous home care hours.

• The computation of the required 8 hours for the CHC level of care applies only to direct patient care provided by a nurse, a homemaker or a hospice aide.

Calculation sample: Your Day 1 of Service Nurse Hours Aide Hours 8 Hour Aggregate Met? 50% of Aggregate Hours Nursing?

Can You Bill This Day at the CHC Rate? 24-hour day which begins and ends at midnight

5 9.5 Yes – 14.5 hours No No – only 5 hours of the aggregate were nursing

4.75 12 Yes – 16.75 No No – only 4.75 hours

of the aggregate were nursing

Counting overlap of nurse and aide hours:

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 hospice aide or

homemaker. 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.

Hours/ services not counted in the 8-hours computation:

• Computation of hours of care should reflect the total hours of direct care provided for an individual that support the care that is needed. This means that all nursing and aide hours should be included in the daily computation for CHC. If the aide hours exceed the nursing hours on a given day, the provider would be paid as routine home care day rather than as a CHC.

• Deconstructing what is provided in order to meet payment rules is not allowed. In other words, hospices cannot discount any portion of the hospice aide and/or homemaker hours provided in order to qualify for a continuous home care day.

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• Documentation of care, modification of the plan of care and supervision of aides or homemakers would not qualify as direct care nor would it qualify as necessitating the services of more than one provider.

• The services provided by other disciplines such as medical social workers or pastoral counselors are an integral part of the care provided to a hospice patient; however, these services are not included in the regulatory definition of continuous care and are not counted towards total hours of

continuous care. However, the services of social workers and pastoral counselors would be expected during these periods of crisis, if warranted, as part of hospice care and are included in the provisions of routine hospice care.

CHC

B

ILLING AND

D

ATA

R

EPORTING

Billing: The amount of payment for CHC is determined based on the number of hours, reported in

increments of 15 minutes, of continuous care furnished to the patient on that day. (These increments are used in calculating the payment rate) The continuous home care rate is divided by 24 hours in order to arrive at an hourly rate. (A minimum of 8 hours must be provided)

Payment is based upon the number of 15-minute increments that are billed for 32 or more units (4 units of 15 minutes equals one hour). Rounding to the next whole hour is no longer applicable. Units should only be rounded to the nearest increment. Billing for CHC should not reflect nursing shifts and non-direct patient increments (e.g., meal beaks, report, and education of staff). (CMS, Chapter 11, 30.3, 2010)

Site of care billing codes:

• Q5001 - hospice care provided in patient's home/residence • Q5002 - hospice care provided in assisted living facility

• Q5003 – hospice care provided in nursing long term care facility (LTC) or the non-skilled nursing facility (NF) portion of a dually certified nursing facility who is receiving unskilled care from the facility staff. The determining factor in deciding which site of service code to report is the level of care (skilled or unskilled), being provided by the facility staff to the hospice patient.

• Q5009 - hospice care provided in a place not otherwise specified

• Q5010 – hospice care provided in a hospice residential facility or a hospice facility which is also certified to provide inpatient care (CMS, Change Request 6905).

Visit Data: Effective January 1, 2010, Medicare required hospices to report additional detail for visits on

their claims. For all Routine Home Care (RHC), Continuous Home Care (CHC) and Respite care billing, Medicare hospice claims should report each visit performed by nurses, aides, and homemakers who are employed by the hospice, and their associated time per visit in the number of 15 minute increments, on a separate line.

CHC

R

ISK

A

REAS

Hospices across the country are experiencing increasing scrutiny of claims submitted for continuous home care. Payment of claims for continuous home care may be denied because:

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• Computation of continuous care hours is incorrect (for example, not eight hours within a 24 hour period beginning and ending at midnight; not predominantly nursing care; etc)

There is also an increase in fraud investigations related to continuous care. In 1999, the Office of the Inspector General identified “billing for a higher level of service than necessary” (for example,

continuous care or the general inpatient level of care) as an area where hospices might be vulnerable to fraud and abuse. Investigators are primarily concerned with providers who:

• Routinely offer continuous care days to all patients and prospective patients residing in a facility when contracting with the facility. This is perceived as a violation of the Anti-Kickback Statute and as an inducement for referrals.

• Do not provide continuous care to eligible patients. Medicare certified hospice providers are required to provide all levels of care, including CHC.

• Provide a significant amount of continuous care to ineligible patients, particularly in nursing facilities.

CHC Compliance Monitoring

CHC is a challenging care level to manage. Hospices should continually audit and monitor its practices related to CHC as a component of their compliance and QAPI programs. Specifically, hospices should evaluate:

• Policies and procedures related to CHC that specify CHC eligibility and documentation requirements;

• Staffing levels to ensure the availability of continuous care when needed;

• Processes for assessing and referring patients for CHC, obtaining physician orders, updating the patient’s plan of care, and scheduling staff;

• Staff training regarding providing and documenting CHC; • Training billing staff regarding CHC billing/coding requirements;

• Procedures related to ongoing discharge planning to ensure the patient returns to RHC as soon as feasible; and

• Ongoing audits of clinical records to ensure that documentation supports the patient’s need for continuous care on each day it is provided and that the care provided effectively addresses that need.

B

IBLIOGRAPHY

:

CMS. (2010, APR). Chapter 11 -40.2.1 . Retrieved from Medicare Internet Only Manuals:

http://www.cms.gov/manuals/downloads/clm104c11.pdf

CMS. (2010). Chapter 11, 30.3. Retrieved from CMS Internet Only Manuals:

http://www.cms.gov/manuals/downloads/clm104c11.pdf

CMS. (2011, MAR). Chapter 9 - 40.2.1. Retrieved from CMS Internet Only Manuals:

http://www.cms.gov/manuals/Downloads/bp102c09.pdf

CMS. (2004). Subpart G—Payment for Hospice. Retrieved from edocket.gpo:

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8 | © National Hospice & Palliative Care Organization 2011. All rights reserved.

CMS. (2010, APR). Transmittal, Change Request 6905. Retrieved from CMS Transmittals:

http://www.cms.gov/Transmittals/downloads/R1955CP.pdf

CMS. (2010). State Operations Manual, Section 2080C. Retrieved from CMS Internet Only Manuals:

http://www.cms.gov/manuals/downloads/som107c02.pdf

Appendix I

C

ONTINUOUS

H

OME

C

ARE REGULATIONS

Subpart F, Medicare hospice regulations: § 418.204 Special coverage requirements.

(a) Periods of crisis. Nursing care may be covered on a continuous basis for as much as 24 hours a day during periods of crisis as necessary to maintain an individual at home. Either homemaker or home health aide (also known as hospice aide) services or both may be covered on a 24-hour continuous basis during periods of crisis but care during these periods must be predominantly nursing care. A period of crisis is a period in which the individual requires continuous care to achieve palliation or management of acute medical symptoms. (CMS, 42 CFR Ch. IV (10–1–10 Edition), 2009)

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9 | © National Hospice & Palliative Care Organization 2011. All rights reserved. § 418.302 Payment procedures for hospice care

(a) HCFA establishes payment amounts for specific categories of covered hospice care. (b) Payment amounts are determined within each of the following categories:

(2) Continuous home care day. A continuous home care day is a day on which an individual who has elected to receive hospice care is not in an inpatient facility and receives hospice care consisting predominantly of nursing care on a continuous basis at home. Home health aide (also known as a hospice aide) or homemaker services or both may also be provided on a continuous basis. Continuous home care is only furnished during brief periods of crisis as described in Sec. 418.204(a) and only as necessary to maintain the terminally ill patient at home.

(e) The intermediary makes payment according to the following procedures:

(3) On any day on which the patient is not an inpatient, the hospice is paid the routine home care rate, unless the patient receives continuous care as defined in paragraph (b)(2) of this section for a period of at least 8 hours. In that case, a portion of the continuous care day rate is paid in accordance with paragraph (e)(4) of this section.

(g) Payment for routine home care and continuous home care is made on the basis of the

geographic location where the service is provided (CMS, 42 CFR Ch. IV (10–1–10 Edition), 2009).

Appendix II

Centers for Medicare and Medicaid Services

Questions and Answers related to hospice continuous home care

CMS publishes answers to specific questions about hospice regulations on a regular basis. Questions and Answers can be found at the CMS Hospice Center at: https://www.cms.gov/center/hospice.asp Look for the Questions and Answers link at the bottom of the right column in the Hospice Center. Published 02/13/2008 08:13 AM | Updated 04/21/2011 04:00 PM | Answer ID 8915

Q - If a hospice patient is at a contracted nursing home receiving Routine Home Care or Continuous Home Care, are the nursing home staff’s patient care visits to the patient also included?

A - No – the number of visits to be included on the claims form is the number of visits provided by the

hospice staff. (Revised)

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Published 04/09/2010 11:47 AM | Updated 03/29/2011 04:08 PM | Answer ID 10005

Q- Which site of service code should be reported when a hospice patient resides in a hospice facility and is receiving the routine home care (RHC) or continuous home care (CHC) level of care?

A - Effective for claims with dates of service on or after October 1, 2010, hospices should report new

HCPCS code Q5010 when Routine Home Care (RHC) or Continuous Home Care (CHC) is provided at a hospice residential facility or a hospice facility which is also certified to provide inpatient care. For claims with dates of service prior to October 1, 2010, when recording the site of service for a hospice patient who received RHC and resided in a hospice inpatient facility, hospices should code the location as Q5006. For claims with dates of service prior to October 1, 2010, when recording the site of service for a hospice patient who received RHC or CHC and resided in a hospice residential facility, hospices should code the location as Q5009.

Published 02/13/2008 07:56 AM | Updated 04/21/2011 04:00 PM | Answer ID 8904

Q- How are visits counted for continuous home care (CHC)?

A - CHC visits are counted in the same manner as Routine Home Care visits. An example of counting CHC

visits would be where a registered nurse provides 4 hours of care in the morning and returns later in the day to provide 4 more hours of care in the evening; 2 nursing visits would be counted. If 3 nurses (in 3 consecutive 8-hour shifts) and one aide provide 24 hrs of CHC in a 24 hour period, 3 nursing visits and 1 aide visit would be counted. (Revised)

Reference: http://www.cms.hhs.gov/transmittals/downloads/R1494CP.pdf

Published 09/29/2006 10:20 AM | Updated 03/29/2011 04:08 PM | Answer ID 7912

Q- Who should provide dominant nursing care in a hospice setting for continuous home care?

A - The care must be predominantly nursing care provided by either a registered nurse (RN) or licensed

practical nurse (LPN). In other words, more than half of the hours of care are provided by the RN or LPN. Homemaker or hospice aide services may be provided to supplement the nursing care. (Revised) Reference: http://www.cms.hhs.gov/transmittals/downloads/R121BP.pdf

Published 09/29/2006 10:25 AM | Updated 04/29/2011 02:43 PM | Answer ID 7915

Q - How is continuous home care (CHC) level of care billed?

A - Services at the CHC level of care must be billed using separately dated line items which report the

number of hours of care provided in 15-minute increments.

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Published 09/29/2006 10:33 AM | Updated 03/29/2011 04:08 PM | Answer ID 7921

Q - How should hospice service date reporting appear on claims for continuous home care (CHC) and other levels of care?

A - For services provided on or after January 1, 2007, service date reporting for continuous home care

(CHC) lines is as follows:

• For revenue code 652 (CHC), report a separately dated line item for each day that continuous home care is provided, reporting the number of hours, or parts of hours rounded to 15-minute increments, of continuous home care that was provided on that date; and

• For other level of care revenue codes, report a separate line for each level of care provided at each service location type as described in the instructions for Healthcare Common Procedure Coding System (HCPCS) coding (FL 44).

• In addition, as of 4/29/2010, CR 6791 requires that a separate service line for each level of care should be reported each time the level of care changes. For example, if the level of care starts at routine home care, then becomes continuous home care, followed by another period of routine home care, the claim should report two lines for routine home care and one line for each day of CHC. The line item date of service for each of the level of care lines should reflect the first day at that level of care for the time period represented by that line. (Revised)

Reference:http://www.cms.hhs.gov/mlnmattersarticles/downloads/MM5345.pdf

http://www.cms.hhs.gov/transmittals/downloads/R1011CP.pdf and

http://www.cms.gov/transmittals/downloads/R1897CP.pdf

Published 02/13/2008 07:48 AM | Updated 05/04/2011 05:44 PM | Answer ID 8900

Q - How should hospice providers count patient care visits in a facility that is staffed 24 hours a day? A - As hospices are not required to count visits by non-hospice staff to hospice patients receiving general

Inpatient Care or respite care in contract facilities. However, for hospice patients receiving General Inpatient Care or respite care in hospice facilities, all visits related to the palliation and management of the terminal illness must be counted.

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Regarding recording of visits when a Medicare hospice patient is residing in a facility and receiving routine home care (RHC) or continuous home care (CHC), the following guidance applies to any hospice patient living in a facility, as the facility is the patient's home. Visits which are part of room and board services and which are provided to a RHC or CHC patient residing in a facility should NOT be reported on hospice claims to Medicare (regardless of whether those services are being provided by hospice staff or facility staff not employed by the hospice). Room and board services may include, but are not limited to, delivery of meals, changing bed linens, housekeeping tasks, etc. Hospices should only report visits which are reasonable and necessary for the palliation and management of the terminal illness and related conditions.

When making the determination as to whether or not a particular visit should be reported, a hospice should consider whether the visit would have been reported, and how it would have been reported, if the patient were receiving RHC in his or her private home. If a group of tasks would normally be performed in a single visit to a patient living in his or her private home, then the hospice should count the tasks as a single visit for the patient residing in a facility. Hospices should not record a visit every time a staff member enters the patient's room. Hospices should use clinical judgment in counting visits and summing time. (Revised)

References: http://www.cms.hhs.gov/transmittals/downloads/R1494CP.pdf and

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