(Medicare Benefit Policy Manual)

Determination:  The nurse provided 6 hours of direct skilled nursing care; the aide provided 4 hours of direct care resulting in a total of 10 hours of registered nurse and hospice aide care. Since at least 6 of the 10 hours were direct nursing care, and since nursing ca re was the predominant service provided during the 10 hours, the care meets the criteria for CHC. In addition, since the nurse and the aide provided direct care for the patient simultaneously, it would be appropriate to bill for each resulting in total of 10 billable hours. The patient received 12 hours of care. The 2 hours for the social worker are not counted towards the CHC hours. Medicares requirements for coverage of CHC are that at least 8 hours of predominantly nursing care are needed in order to manage an acute medical crisis as necessary to maintain the individual at home. When a hospice determines that a beneficiary meets th e requirements for CHC, appropriate documentation must be available to support the requirement 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. This would include the appropriate documentation of the situation and the need for continuous care services consistent with the plan of care.  Continuous home care is only furnished during brief periods of crisis and covered only as necessary to maintain the terminally ill individual at home.   40.2.2 - Respite Care  (Rev. 188, Issued: 05- 01-14; Effective: 08 -04-14; Implementation: 08 -04-14)  Respite care is short -term inpatient care provided to the individual only when necessary to relieve the family members or other persons caring for the individual at home.  Respite care may only be provided in a Medicare participating hospital or hospice inpatient facility, or a Medicare or Medicaid participating nursing facility.  Respite care may be provided only on an occasional basis and may not be reimbursed for more than 5 consecutive days at a time.  Respite care provided for more than 5 consecutive days at a time must be billed as routine home care for day 6 and beyond, and the patient may be liable for room and board charges for day 6 and beyond.  See 40.1.5 for additional information.  40.2.3 - Bereavement Counseling  (Rev. 141, Issued: 03- 02-11, Effective: 01 -01-11: Implementation: 03- 23-11)  Bereavement counseling consists of counseling services provided to the individuals family before and after the individuals death.  Bereavement counseling is a required hospice service, provided for a period up to 1 year following the patients' death.  It  is not separately reimbursable.   Bereavement specifics are found in Pub. 100- 07, State Operations Manual, Appendix M, 42 CFR 418.64(d)(1) , L596  40.2.4 - Special Modalities  (Rev. 188, Issued: 05- 01-14; Effective: 08 -04-14; Implementation: 08 -04-14)  A hospice may use chemotherapy, radiation therapy, and other modalities for palliative purposes if it determines that these services are needed.  This determination is based on the patients condition and the individual hospices care -giving philosophy.  N o additional Medicare payment may be made regardless of the cost of the services.   40.3 - Contracting With Physicians  (Rev. 141, Issued: 03- 02-11, Effective: 01 -01-11: Implementation: 03- 23-11)  Section 1861(dd)(2)  of the Act allows hospices to contract for physician services.  Medical directors and physician members of the IDG are not required to be employed by the hospice.  These physicians can be under contract with the hospice.  Although the Act does not speci fy what the terms of that contract must be, requirements at 42 CFR 418.64(a) , 418.100(e) , and 418.102(a)  are applicable to hospice, as well as all other responsibilities under the hospice conditions of participation.  Hospices retain professional management responsibilities for these services and must ensure that qualified persons furnish them in a safe and effective manner.  All physician employees and those under contract must function under the supervision of the hospice medical director.   Since nurse practitioners are not included in the definition of a physician, this section does not apply to nurse practitioners   40.4 - Core Services  (Rev. 141, Issued: 03- 02-11, Effective: 01 -01-11: Implementation: 03- 23-11)  With the exception of physician services, substantially all core services must be provided directly by hospice employees on a routine basis.  These services must be provided in a manner consistent with acceptable standards of practice.  The following are h ospice core services:    Physician services.    Nursing services, (routinely available and/or on call on a 24- hour basis, 7 days a week) provided by or under the supervision of an RN functioning within a plan of care developed by the hospice IDG in consultation with the patients attending physician, if  the patient has one.    Medical social services by a qualified social worker under the direction of a physician.   Counseling (including, but not limited to, bereavement, dietary, and spiritual counseling) with respect to care of the terminally ill individual and adjustment to death.  The hospice must make bereavement services available to the family and other individuals identified in the bereavement plan of care up to 1 year following the death of the patient.   The hospice may contract for physician services as specified in the Conditions of Participation.   40.4.1 - Contracting for Core Services  (Rev.  141, Issued: 03- 02-11, Effective: 01 -01-11: Implementation: 03- 23-11)  A hospice may use contracted staff, if necessary, to supplement hospice employees in order to meet the needs of patients under extraordinary or other non- routine circumstances.   Arrangements made by a hospice to furnish items or services must be such that receipt of payment by the hospice for the services relieves the beneficiary of liability or any other persons to pay for the services.  Whether the services and items are furnish ed by the hospice itself or by another organization under arrangements made by the hospice, both must agree not to charge the patient for covered services and items and must agree to return money incorrectly collected.   A hospice that has a written agreement with another agency, individual, or organization to furnish any services under arrangement must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care.  Arranged services must be supported by written agreements that require that all services be --  (1)  Authorized by the hospice;   (2)  Furnished in a safe and effective manner by qualified personnel; and   (3)  Delivered in accordance with the patient's plan of care.   40.4.1.1 - Contracting for Highly Specialized Nursing Services  (Rev.  141, Issued: 03- 02-11, Effective: 01 -01-11: Implementation: 03- 23-11)  A hospice may contract for the services of a registered nurse if the services are highly specialized, provided non- routinely, and so infrequently that the provision of such services directly would be impracticable and prohibitively expensive.  Highly specialized services are determined by the nature of the service and the nursing skill level required to be proficient in the service.  For example, a hospice may need to contract with a pediatric nurse if it cares for pediatric patients infrequently and if employing a pediatric nurse would be impracticable and expensive.  Continuous care is not a highly specia lized service, because while time intensive, it does not require highly specialized nursing skills.   40.4.2 - Waiver for Certain Core Staffing Requirements  (Rev. 141, Issued: 03- 02-11, Effective: 01 -01-11: Implementation: 03- 23-11)  Hospices are prohibited from contracting with other hospices and non- hospice agencies on a routine basis for the provision of the core services of nursing, medical social services and counseling to hospice patients.  A hospice may, however, enter into arra ngements with another hospice program or other entity for the provision of these core services in extraordinary, exigent, or other non- routine circumstances.  An extraordinary circumstance generally would be a short -term temporary event that was unanticipated.  Examples of such circumstances might include unanticipated periods of high patient loads, caused by an unexpectedly large number of patients requiring continuous care simultaneously, temporary staffing shortages due to illness, receiving patients eva cuated from a disaster such as a hurricane or a wildfire, or temporary travel of a patient outside the hospices service area.  The hospice that contracts for services must maintain professional management responsibility for all services provided under arr angement or contract at all times and in all settings.  Regulations at 42 CFR 418.100(e)  discuss the professional management responsibilities of the hospice for services provided under arrangement.   Hospices must maintain evidence of the extraordinary circumstances that required them to contract for the core services and comply with the following:   (a) The hospice must ensure that contracted staff is providing care that is consistent with the hospice philosophy and the patient's plan of care and is actively participating in the coordination of all aspects of the patients hospice care.   Hospices may not routinely contract for a specific level of care (e.g., continuous care) or for specific hours of care (e.g., evenings and week -ends).   40.4.2.1 - Waiver for Certain Core Nursing Services  (Rev. 141, Issued: 03- 02-11, Effective: 01 -01-11: Implementation: 03- 23-11)  The Conditions of Participation allow CMS to waive the requirement that a hospice provide nursing services directly, if the hospice is located in a non- urbanized area.  The location of a hospice that operates in several areas is considered to be the locati on of its central office.  The hospice must provide evidence to CMS that it has made a good faith effort to hire a sufficient number of nurses to provide services.  CMS may waive the requirement that nursing services be furnished by employees based on the following criteria:    The location of the hospice's central office is in a non- urbanized area as determined by the Bureau of the Census.   There is evidence that the hospice was operational on or before January 1, 1983, including the following:    Proof that the organization was established to provide hospice services on  or before January 1, 1983;    Evidence that hospice -type services were furnished to patients on or before January 1, 1983;  and   Evidence that hospice care was a discrete activity rather than an aspect of another type of providers patient care program on or before January 1, 1983.   By virtue of the following evidence that a hospice made a good faith effort to hire nurses:    Copies of advertisements in local newspapers that demonstrate recruitment efforts;    Job descriptions for nurse employees;    Evidence that salary and benefits are competitive for the area; and    Any other recruiting activities (e.g., recruiting efforts at health fairs and contacts with appropriate personnel at other providers in the area).   A waiver remains in effect for a 1 -year period.  A waiver may be extended for two additional 1- year periods.  Prior to each additional year, the hospice must request the extension and certify that the employment market for appropriate personnel has not changed significantly since the initial waiver was granted if this is the case.  No additional evidence is required with this certification.   Waiver requests and any extensions with supporting documentation must be sent to the regional office for review.  Regional offices have the authority to review, and approve, or deny the waiver application.  40.5 - Non-core Services  (Rev. 188, Issued: 05- 01-14; Effective: 08 -04-14; Implementation: 08 -04-14)  In addition to the hospice core services (physician services, nursing services, medical social services, and counseling), the following services must be provided by the hospice, either directly or under arrangements, to meet the needs of the patient and fa mily:   Physical and occupational therapy and speech- language pathology services.   Hospice aide services.  A hospice aide employed by a hospice, either directly or under contract, must meet the qualifications required by 1891(a)(3)  of the Act and implemented at 42CFR418.76.   Homemaker services.    Volunteers.    Medical supplies (including drugs and biologicals on a 24- hour basis) and the use of medical appliances related to the terminal illness and related conditions.   Short -term inpatient care (including respite care and interventions necessary for pain control and acute and chronic symptom management) in a Medicare/Medicaid participating facility.