evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
Medicare covers two levels of inpatient care: respite care for relief of the patients caregivers, and general inpatient care which is for pain control and symptom management.  General inpatient care (GIP) may only be provided in a Medicare participating h ospital, SNF, or hospice inpatient facility.  Respite care may only be provided in a Medicare participating hospital or hospice inpatient facility, or a Medicare or Medicaid participating nursing facility.  General inpatient care is allowed when the patients medical condition warrants a short -term inpatient stay for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings.  General inpatient care under the hospice benefit is not equivalent to a hospital level of care under the Medicare hospital benefit.  For example, a brief period of general inpatient care may be needed in some cases when a patient elects the hospice benefit at the end of a covered hospital stay.  If a patient in this circumstance continues to need pain control or symptom management, which cannot be feasibly provided in other settings while the patient prepares to receive hospice home care, general inpatient care is appropriate.   Other examples of appropriate general inpatient care include a patient in need of medication adjustment, observation, or other stabilizing treatment, such as psycho- social monitoring.  It is not appropriate to bill Medicare for general inpatient care days for situations where the individuals caregiver support has broken down unless the coverage requirements for the general inpatient level of care are otherwise met.  For a hospice to provide and bill for the general inpatient level of care, the patient must  require an intensity of care directed towards pain control and symptom management that cannot be managed in any other setting.  Respite care is short -term inpatient care provided to the individual only when necessary to relieve the family members or other persons who normally care for the individual at home.  Respite care may be provided only on an occasional basis and may not be reimbursed for more than 5 consecutive days at a time.
(Medicare Benefit Policy Manual)
Payment for the sixth and any subsequent day of respite care is made at the routine home care rate, and the patient would be liable for room and board.  Respite care cannot be provided to hospice patients who reside in a facility (such as a long term care nursing facility).  Provision of respite care depends upon the needs of the patient and of the patients caregiver, within the limitations given.   Several examples of appropriate respite care for a patient who does not reside in a facility include providing a few days for the caregiver to rest at home, to visit family, attend a wedding, or attend a graduation for a needed break, or providing a few da ys immediately following a GIP stay if the usual caregiver has fallen ill.  See also, section 40.2.2.  Note that hospice inpatient care in an SNF or NF serves to prolong current benefit periods for general Medicare hospital and SNF benefits.  This could potentially affect patients who revoke the hospice benefit.  If a hospice patient receives general inpatient care for 3 days or more in a hospital, and chooses to revoke hospice, then the 3- day stay (although not equivalent to a hospital level of care) would still qualify the beneficiary for covered SNF services.    40.1.6 - Medical Appliances and Supplies  (Rev. 188, Issued: 05- 01-14; Effective: 08 -04-14; Implementation: 08 -04-14)  Medical appliances and supplies may be provided, including drugs and biologicals.  Only drugs as defined in 1861(t) of the Act and which are used primarily for the relief of pain and symptom control related to the individuals terminal illness are covered .  This includes both prescription and over -the-counter drugs as defined in 1861(t) of the Act.  Appliances may include covered durable medical equipment as described in 42 CFR  410.38 as well as other self -help and personal comfort items related to the palliation or management of the patients terminal illness.  Equipment is provided by the hospice for use in the patients home while the patient is under hospice care.  Medical supplies include those that are part of the written plan of care
(Medicare Benefit Policy Manual)
and that are for palliation and management of the terminal illness or related conditions.  40.1.7 - Hospice Aide and Homemaker Services  (Rev. 141, Issued: 03- 02-11, Effective: 01 -01-11: Implementation: 03- 23-11)  A hospice aide is a person who meets the requirements described in the Conditions of Participation.  Hospice aides may provide personal care services.  Aides may also perform household services to maintain a safe and sanitary environment in areas of the home used by the patient, such as changing the bed or light cleaning and laundering essential to the comfort and cleanliness of the patient.  Hospice aides are assigned to a specific patient by a registered nurse who is a member of the interdisciplinary group.  Written patient care instructions for a hospice aide must be prepared by a registered nurse who is responsible for the supervision of a hospice aide.   CMS Conditions of Participation define a qualified homemaker as an individual who meets the requirements described in 42 CFR 418.202(g)  and who has successfully completed hospice orientation addressing the needs and concerns of patients and families coping with a terminal illness.  Homemaker services may include assistance in maintenance of a safe and healthy environment and services to enabl e the individual to carry out the plan of care.  40.1.8 - Physical Therapy, Occupational Therapy, and Speech-Language Pathology  (Rev. 141, Issued: 03- 02-11, Effective: 01 -01-11: Implementation: 03- 23-11)  Physical therapy, occupational therapy, and speech -language pathology services may be provided for purposes of symptom control or to enable the individual to maintain activities of daily living and basic functional skills.  Also, see 40.5 regarding waivers available under certain conditions for provision of these services.   40.1.9 - Other Items and Services  (Rev. 188, Issued: 05- 01-14; Effective: 08 -04-14; Implementation: 08 -04-14)
(Medicare Benefit Policy Manual)
40.1.9 - Other Items and Services  (Rev. 188, Issued: 05- 01-14; Effective: 08 -04-14; Implementation: 08 -04-14)  Any other item or service which is included in the plan of care and for which payment may otherwise be made under Medicare, in accordance with title XVIII of the Social Security Act, is a covered service under the Medicare hospice benefit.  The hospice is responsible for providing any and all services indicated in the plan of care as reasonable and necessary for the palliation and management of the terminal illness and related conditions.  The hospice Interpretive Guidelines for 42 CFR 418.54(a) , published via a Survey and Certification letter (S & C 09 -19, Advance Copy- Hospice Program Interpretive Guidance Version 1.1), require that the initial assessment be conducted in the location where hospice services will be provided.  The plan of care is developed from that initial assessment and from the comprehensive assessment.  Ambulance transports to a patients home which occur on the effective date of the hospice election (i.e., the date of admission), would occur prior to the initial assessment and therefore prior to the plan of cares development.  As such, these transports are not the responsibility of the hospice.  Medicare will pay for ambulance transports of hospice patients to their home, which occur on the effective date of hospice election, t hrough the ambulance benefit rather than through the hospice benefit.  Ambulance transports of a hospice patient, which are related to the terminal illness and which occur after the effective date of election, are the responsibility of the hospice.   EXAMPLE:   A hospice determines that an existing patients condition has worsened and has become medically unstable.  An inpatient stay will be necessary for proper palliation and management of the condition.  The hospice adds this inpatient stay to the plan of care and decides that, due to the patients fragile condition, the patient will need to be transported to the hospital by ambulance.  In this case, the ambulance service becomes a covered hospice service.   40.2 - Special Services  (Rev. 1, 10- 01-03) A3-3143.2, HO -230.3
(Medicare Benefit Policy Manual)
40.2.1 - Continuous Home Care (CHC)  (Rev.  12400; Issued: 12- 06-23; Effective: 01 -01-24; Implementation: 01- 02-24) Continuous home care may be provided only during a period of crisis as necessary to maintain an individual at home. A period of crisis is a period in which a patient requires continuous care which is predominantly nursing care to achieve palliation or mana gement of acute medical symptoms. If a patients caregiver has been providing a skilled level of care for the patient and the caregiver is unwilling or unable to continue providing care, this may precipitate a period of crisis because the skills of a nurse  may be needed to replace the services that had been provided by the caregiver. This type of care can also be given when a patient resides in a long term care facility. However, Medicare regulations do not permit CHC to be provided in an inpatient facility (a hospice inpatient unit, a hospital, or SNF).  The hospice must provide a minimum of 8 hours of nursing, hospice aide, and/or homemaker care during a 24- hour day, which begins and ends at midnight. This care need not be continuous, e.g., 4 hours could be provided in the morning and another 4 hours in t he evening. In addition to the 8 hour minimum, the services provided must be predominantly nursing care, provided by either an RN, an LPN, or an LVN. Services provided by a nurse practitioner that, in the absence of a nurse practitioner, would be performed  by an RN, LPN, or LVN, are nursing services and are paid at the same continuous home care rate. This means that more than half of the hours of care are provided by an RN, LPN, or LVN. Homemaker or hospice aide services may be provided to supplement the nursing care.  NOTE:  When fewer than 8 hours of care are required, the services are covered as routine home care rather than continuous home care.  Nursing care in the hospice setting can include skilled observation and monitoring when necessary, and skilled care needed to control pain and other symptoms.  The development of the CHC rate included the daily costs of nursing, hospice aide, social worker, and therapy visits; drugs; supplies and equipment; and the average daily cost of the hospice IDG. However, the statute limits the billable CHC hours of direct
(Medicare Benefit Policy Manual)
CHC rate included the daily costs of nursing, hospice aide, social worker, and therapy visits; drugs; supplies and equipment; and the average daily cost of the hospice IDG. However, the statute limits the billable CHC hours of direct  patient care to care provided by a nurse, a homemaker, or a hospice aide. Medicare regulations require that an hourly payment be made. While in the majority of situations, one individual would provide continuous care during any given hour, there may be circumstances where the patients needs require direct interventions by more than one covered discipline resulting in an overlapping of hours between the nurse and hospice aide. In these circumstances, the overlapping hours would be counted separately. The total hours paid cannot exceed 24 hours per day.  The hospice would need to ensure that these direct patient care services are clearly documented and are reasonable and necessary. Computation of hours of care should also reflect the total hours of direct care provided to an individual that support the car e that is needed and required. This means that all nursing and aide hours should be included in the computation for CHC and when the aide hours exceed the nursing hours, CHC would be denied and routine payment will be made. The statutory definition of cont inuous home care is meant to include the full range of services needed to achieve palliation and management of acute medical situations. Deconstructing what is provided in order to meet payment rules is not allowed. In other words, hospices cannot discount  any portion of the hours provided in order to qualify for a continuous home care day.  Documentation of care, modification of the plan of care, and supervision of aides or homemakers would not qualify as direct care nor would these activities qualify as necessitating the services of more than one care provider. In addition, while the service s provided by other disciplines such as medical social workers , pastoral counselors , MFT or MHCs are  an integral part of the care provided to a hospice patient, these services are not included in the statutory definition of continuous care and are not coun ted towards total hours of continuous care. However, the services of social workers , pastoral counselors , MFT or MHCs  would be expected during these periods of crisis, if warranted as part of hospice care, and are included in the provisions of routine hospice care.  The following are used to illustrate circumstances that may qualify as CHC. This list is not all -inclusive nor does it indicate that if a patient presents with
(Medicare Benefit Policy Manual)
warranted as part of hospice care, and are included in the provisions of routine hospice care.  The following are used to illustrate circumstances that may qualify as CHC. This list is not all -inclusive nor does it indicate that if a patient presents with similar situations, that it would constitute CHC.  1. Frequent medication adjustment to control symptoms/collapse of family support system
(Medicare Benefit Policy Manual)
Situation A:  The patient has had a central venous catheter inserted to provide access for continuous Fentanyl drip for pain control and for the administration of antiemetic medication to control continuous nausea and vomiting. The nurse spends 2 hours teaching the fam ily members how to administer IV medications. She returns in the evening for 1 hour. The hospice aide provides 3 hours of care. The nurse spends 2 hours phoning physicians, ordering medications, documenting and revising the plan of care.   Determination:  Despite 8 hours of service, this does not constitute CHC since 2 of the 8 hours were not activities related to direct patient care.   Situation B:  The patient experiences new onset seizures. He continues to have episodes of vomiting. The nurse remains with the patient for 4 hours (10 AM  2 PM) until the seizures cease. During that time she provides skilled care and family teaching. The patients wi fe states she is unable to provide any more care for her husband. A hospice aide is assigned to the patient for monitoring for 24 hours, beginning at 2:00 PM, with a total of 8 hours of direct care in the first day. The nurse returns intermittently for a total of an additional 5 hours to administer medications, assess the patient and to relieve the aide for breaks. The social worker provides 3 hours of services to work with the patients wife in identifying alternative methods to care for the patient.   Determination:  This qualifies as a continuous home care day. This constitutes a medical crisis, including collapse of family structure. The caregiver has been providing skilled care and the change in the patients condition requires the nurses interventions. Since ther e is no overlap in nursing care, 17 hours of care (i.e., 9 hours of nursing care and 8 hours of aide care) would be computed as CHC. The social worker hours would not be incorporated. If the caregiver had been providing custodial care and his  medical crisis resolved within a short time frame, this situation would not have qualified as CHC.   2. Symptom management/rapid deterioration/imminent death
(Medicare Benefit Policy Manual)
2. Symptom management/rapid deterioration/imminent death   Situation A:  77-year-old patient with lung cancer whose caregiver is 80 years old. The caregiver has been caring for this patient for 4 months and is now exhausted and scared. The care provided consists of assisting with bathing, assisting the patient to ambulate, pre paring meals, housekeeping and administering oral medications. Since the patient is dyspneic at rest, she requires assistance in all ADLs, which equates to 9 hours of assistance within a 24- hour period.   Determination:  This would not qualify as CHC since there is little nursing care that requires a nurse. The patient would however be a candidate for an inpatient respite level of care.
(Medicare Benefit Policy Manual)
Determination:  This would not qualify as CHC since there is little nursing care that requires a nurse. The patient would however be a candidate for an inpatient respite level of care.   Situation B:  The patients condition deteriorates. The patient now has circumoral cyanosis, respiratory rate of 44 and labored with intermittent episodes of apnea. The nurse performs a complete assessment and teaches the caregiver on methods to make the patient comfor table. The nurse returns twice within the 24 -  hour period to assess the patient. She revises the plan of care after conferring with the patients attending physician and with the hospice physician. The homemaker and hospice aide are sent to assist the caregiver. Within the 24 -hour period, the direct care provided by the nurse equates to 3 hours, homemaker with 2 hours, and hospice aide of 6 hours.   Determination:  Since only 3 of the 11 hours were skilled care requiring the services of a nurse, this would not constitute CHC. In this situation, the care required is not predominantly nursing but are comprised of services provided by a hospice aide. In addition, it would not be correct to discount any portion of the hospice aides hours or to provide these services gratis in order to qualify for the CHC benefit.   Situation C:  The next day, the patients condition deteriorates further. She has increased periods of apnea and air hunger. In addition she is experiencing continuous vomiting and increasing pain. Her blood pressure is beginning to decrease and her respirations are increasing. The nurse remains at the patients bedside for 4 hours while attempting to control her pain and symptoms. The hospice aide provides care during 1 hour of this period. The nurse leaves and the hospice aide remains at the bedside for 3 hours. The s ocial worker comes and talks with the caregiver and remains for 1 hour. The nurse returns while the aide leaves. The nurse remains with the patient for 2 hours until she dies. The social worker returns and stays with the caregiver for 1 hour until the mort uary arrives.
(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)
(Medicare Benefit Policy Manual)
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)