5CF92: Hospice Continuous Care Hours Reduction

Reason for Denial
Hospice Continuous Care hours have been reduced to the routine care rate.

How to Avoid This Denial
Submit documentation to provider clear evidence the continuous care is being provided during a period of crisis.

• A period of crisis is defined as a time in which the beneficiary requires predominately nursing care to achieve palliation or management of acute medical symptoms
• For continuous care to be covered, care must be provided for a minimum of eight hours during a 24-hour day which begins and ends at midnight
• The documentation submitted for review should reflect the care provided was predominately nursing care by either a registered nurse (RN) or licensed practical nurse (LPN), which means at least half of the hours of care were provided by an RN or LPN
• Ensure documentation submitted for review includes the number of hours of care provided by each discipline and it should match the number of units of continuous care hours billed

Resources

• CMS Internet-Only Manual (IOM), Pub. 100-02, Medicare Benefit Policy Manual, Chapter 9, Sections 10, 20.2 and 20.2.1 (PDF)
• CMS IOM, Pub. 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.1 (PDF)
• Code of Federal Regulations, 42 CFR - Sections 418.20, 418.24 and 418.2