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Respite Care

Medicare Benefit Policy Manual (CMS Pub. 100-02) Ch. 9 §40.2.2

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

Inpatient respite care is provided to the beneficiary only when necessary to relieve the family members or other caregivers that are caring for the beneficiary at home. Coverage for respite care does not require a worsening of the beneficiary’s condition. Respite care is short-term inpatient care and is reimbursed for no more than five consecutive days per respite period. This care is provided on an occasional basis. Any number of situations may necessitate respite care.

 Examples of appropriate use of respite care:

  • Caregiver feels if he/she had relief of caregiving responsibilities for a short time, the caregiver could resume or continue caring for the beneficiary at home again.
  • Caregiver is temporarily unable to provide care to beneficiary because of personal illness.
  • Caregiver needs to go out of town overnight.

 Examples in which respite care is not appropriate:

  • The beneficiary did not have a caregiver providing care in the home on a regular basis.
  • The beneficiary was already in 24-hour care at a care facility and the desire for respite care is not related to a patient caregiver need.
  • The plan of care clearly states this is a permanent placement to a residential facility.
  • The respite care was not provided in a participating hospice inpatient unit, or a participating skilled nursing facility (SNF) or nursing facility (NF) that additionally meets the special hospice standards.

 Supportive Documentation for Respite Care

The medical record must show when the level of care was changed to respite care and the reason. The following an example of supportive documentation:

“Caregiver needs relief because beneficiary is keeping caregiver up all night; transfer to appropriate facility. Begin respite care 10 a.m. on 1/1/YY. Mary Nurse, R.N. Caregiver is able to care for beneficiary at home; transfer beneficiary to home on 1/4/YY at 12 noon. Mary Nurse, R.N.”

Updated: 07.25.12


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