Home Health & Hospice Week

Deciding if hospice care reaches the much-higher continuous home care billing level may have gotten a bit easier, thanks to new guidance from the Centers for Medicare & Medicaid Services.

"This guidance on continuous care is the most extensive [CMS] has ever given," cheers Janet Neigh of the Hospice Association of America.

The bare bones of hospice continuous home care (CHC) have been outlined since the hospice benefit's inception in 1983, notes Judi Lund Person with the National Hospice and Palliative Care Organization. The hospice must furnish at least eight hours of direct patient care in a 24-hour period, with at least half of the hours being skilled care coming from a registered or licensed practical nurse.

And CHC is covered "only during periods of crisis and only as necessary to maintain the terminally ill individual at home," CMS says in Feb. 28 memo A-03-016.

CHC pays considerably more than routine home care under the Medicare hospice benefit -$666.52 per day versus $114.20 in 2003.

Hospices have had many questions about the CHC category because of its significantly higher reimbursement rate and because it is relatively little used, Person says. There has been a slight increase in CHC utilization, however, and that's engendering even more questions, Neigh adds.

CMS erases one of the biggest uncertainties about CHC in the memo - whether overlapping hours from a nurse and home health aide count. "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 home health aide," CMS admits. When that occurs, hospices should count the hours separately.

Being able to count those nursing hours is good news for hospices, Neigh says.

Counting the nursing hours is so important because if an aide provides even one more hour of care than a nurse in the 24-hour period, the care gets knocked down to the routine care level, losing $550 for the hospice.

While CMS acknowledges overlapping hours are sometimes acceptable, they certainly shouldn't be commonplace and must be clearly documented. Counting overlapping hours should be the exception rather than the rule, Person notes.

Less promising was the guidance that hospices can't exclude aide hours from the official count to qualify for lucrative CHC payments. "Deconstructing what is provided in order to meet payment rules is not allowed," CMS chides in the memo. "Hospices cannot discount any portion of the hours provided in order to qualify" for a CHC day.

Hospices get very frustrated when they send a nurse out to a patient for four or five hours but can't bill for CHC because the aide has been in the home for six, Person relates.

Without specific guidance, some hospices have figured they could just not report those additional aide hours as a way to make sure they are reimbursed for their costs. "Discounting some of the home health aide or homemaker hours so they do not outweigh the nursing hours is not uncommon," says Neigh. But now CMS has expressly prohibited that practice.

While it might not be the decision hospices wanted, at least they know the rules and can more confidently decide when to claim CHC and when not to, Person says.

Nurse and aide visits are also the only hours that count toward the CHC ratio, CMS clarifies. Medical social workers, pastoral counselors and others are likely to be involved in care during the crisis and should be documented in the medical record, but according to law they simply don't count toward the ratio, the memo points out.

CMS includes five case study examples to illustrate points in the new guidance, including that non-direct patient care also doesn't count toward the eight-hour CHC minimum or the ratio.