5CF95: Hospice Continuous Care Hours, Units Not Reasonable and Necessary

Reason for Denial
Some hospice services for continuous care were denied because the documentation submitted did not support the level of care billed for those hours/units.

How to Avoid This Denial

• Continuous care must be provided for a minimum of eight hours during a 24-hour day (24-hour day begins and ends at midnight). This care may be rendered in any necessary increment as long as the total is at least eight hours of care in a 24-hour period.
• An RN or LPN must provide at least half of the care hours billed
• Continuous care should be initiated when skilled levels of care are needed during crisis situations. A period of crisis is defined as a time in which the patient requires predominately nursing care to achieve palliation or management of acute medical symptoms.
• Documentation should clearly support the reason for continuous care and should illustrate hour-by-hour and day-by-day what services were provided, the patient’s condition, and the type of personnel providing continuous care

Resources

• CMS Internet-Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 10, 20.2 and 20.2.1 (PDF)
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.1 (PDF)