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Continuous Home Care

Medicare Benefit Policy Manual (CMS Pub. 100-02) Ch. 9 §40.2.1External PDF

Medicare Claims Processing Manual (CMS Pub. 100-04) Ch. 11 §30.1 and 30.3External PDF

Continuous home care is to be provided only during periods of crisis to maintain the beneficiary at home. Continuous care cannot be provided in a skilled nursing facility (SNF), inpatient hospital, inpatient hospice facility, a long term care hospital (LTCH), or an inpatient psychiatric facility. A period of crisis is a period of time when the beneficiary requires the higher level of “continuous care” for at least 8 hours in a 24-hour period (midnight to midnight) to achieve palliation or management of acute medical symptoms. The care does not need to be “continuous”, but must total eight hours or more of care within the 24-hour period. The care must be predominantly nursing care provided by an RN, LPN, or LVN. Homemaker or hospice aide services may be provided to supplement the nursing care. This means that at least 50 percent of the total care provided must be provided a nurse. All nursing, aide and homemaker services must be counted into the continuous home care time. Hospices cannot choose to count fewer aide hours than were actually provided to increase the percentage of nursing hours. When aide hours exceed the nursing hours, routine home care must be billed.

Examples of counting continuous home care hours are as follows:

  • If less than 8 hours of care was given or if death occurs before 8 hours, do not count the hours as continuous care; bill the day as a routine home care day.
  • Medical social workers, counselors, pastoral care, and bereavement counseling by any staff member certainly may be appropriate and valuable in the home during a crisis; however, those hours may not be counted in the continuous care hours.
  • If within a 24 hour period, 6 hours of care is provided by a hospice aide, and 4 hours of care is provided by a skilled nurse, do not count the hours as continuous care since at least 50 percent of the total care provided was not provided by a nurse. This would be billed as routine.
  • Care that spans midnight (e.g., 4 hours of skilled nursing care is provided from 8:00 p.m. to 12:00 a.m. and from 12:00 a.m. to 4:00 a.m.) cannot be billed as continuous care hours.

Supportive Documentation for Continuous Home Care

When it is determined that a beneficiary meets the requirements for continuous home care, appropriate documentation must be available to support the requirements 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.

When a level of care changes, the medical record must show the date, time and reason why the level of care changed (e.g., Beneficiary in severe pain, caregiver unable to control. Continuous care began 1/1/YY at 8 a.m., Mary Nurse R.N.). A later entry may read, “Beneficiary’s pain is controlled and caregiver is able to care for beneficiary, routine care to begin 1/3/YY at 7 a.m.” The 1/3/YY day must be billed as a routine care day, because the minimum of 8 hours was not met. Document the interventions and observations to support the need for each hour of continuous care billed.

The supportive documentation should show clearly the beneficiary’s condition warranting the interventions provided by the hospice staff at this higher level of care. The documentation should then describe the beneficiary’s response to care.

Although CHC is billed in 15-minute increments, the supportive documentation is not required to be every 15 minutes. Supportive documentation should be as frequent as necessary to support continued CHC, and is suggested at least hourly.

Updated: 07.25.12


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