RESPITE CARE LEGACY HOSPICE

RESPITE CARE LEGACY HOSPICE

THE BASICS OF RESPITE CARE

WHAT IS RESPITE? Short-term inpatient care provided only when necessary to relieve the family members or other persons caring for the individual at home. Respite care may not be reimbursed for more than 5 consecutive days at a time including the date of admission but not the date of discharge. More than one respite period (of no more than 5 days each) is allowable in a single billing period (CMS, Chap. 11, Sec 30.1, 2011). There is no written guidance from CMS which restricts the use of respite to one time per benefit period.

WHERE CAN RESPITE BE PROVIDED? A Medicare-certified inpatient hospice facility A contracted Medicare-certified hospital or a skilled nursing facility that has the capability to provide 24- hour nursing if the patient s plan of care required that type of nursing intervention.

WHERE RESPITE CARE CANNOT BE PROVIDED? Respite care may not be provided in an assisted living facility because they are regulated at the state level and do not meet the requirement of being a Medicare or Medicaid certified hospital or nursing facility. Respite care may not be provided in a patient s private residence.

WHEN IS RESPITE CARE APPROPRIATE? The caregiver is physically and emotionally exhausted from caring 24/7 for the patient and requires a break. The caregiver would like to attend a family event, such as a wedding, graduation, etc The caregiver is ill and needs a break from patient care to recover.

WHEN IS RESPITE CARE NOT APPROPRIATE? There is no identified caregiver Patient resides in a nursing facility or a facility that provides 24/7 care There is no clear reason for caregiver relief

HOW OFTEN CAN A CAREGIVER ASK FOR RESPITE CARE? More than one respite period (of no more than 5 days each) is allowable in a single billing period. If the beneficiary dies under inpatient respite care, the day of death is paid at the inpatient respite care rate. Frequent use of respite care for one patient or unusual patterns of respite care may be a red flag to your MAC. Documentation must justify the reason for the caregiver relief. (ex.: 5 days of respite with a one day break and another 5 days of respite)

CONSIDERATIONS WHEN CONTRACTING FOR RESPITE CARE 24-hour nursing should be available per the patient s need and plan of care requirements. The contracted facility would provide room & board services and function as the patient s caregiver during the 5 days of inpatient respite per the contractual agreement language. A contract for respite services is required if respite care is not provided in the provider s own facility. The provider should document their efforts to secure a contract at the MC per diem respite rate and if a higher rate was negotiated, the reason why.

CONTRACTUAL CONSIDERATIONS (CONT.) The hospice provider must ensure the following: A copy of the patient s plan of care that specifies the inpatient respite services to be furnished. That the inpatient provider has established patient care policies consistent with those of the hospice and agrees to abide by the palliative care protocols and plan of care established by the hospice for its patients. That the patient s inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility. A copy of the discharge summary must be provided to the hospice at the time of discharge. A copy of the inpatient clinical record is available to the hospice at the time of discharge. The inpatient facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement.

DOCUMENTATION OF INPATIENT RESPITE CARE

HOW SHOULD THE IDT DOCUMENT RESPITE? Documentation should include the following: Reason for respite Dates of respite provision Visits by any hospice discipline during the respite stay Orientation of facility staff to: Patient s POC and advance directives When and how to contact the hospice Hospice IDT visit schedule How to contact the patient s caregiver

PHYSICIAN ORDERS AND RESPITE CARE CMS does not specifically state that a physician order is required to change from routine home care to inpatient respite level of care. Legacy Hospice requires all offices to obtain physician s orders for Respite Care.

HOSPICE STAFF VISITS DURING RESPITE Routine visits by all disciplines should continue. When documenting visits, chose visit type Respite if available. If Respite care is provided in a hospital, HCA visits will be held and will be provided by hospital staff. A physician s order to hold HCA visits should be obtained for dates of respite care.

BILLING AND DATA REQUIREMENTS FOR INPATIENT RESPITE CARE

BILLING AND DATA REPORTING Hospices are paid at the inpatient respite care rate for each day on which the beneficiary is in an approved inpatient facility and is receiving respite care. Payment for respite may be made for a maximum of 5 continuous days including the date of admission but not counting the day of discharge. Payment for the 6 th and subsequent days is to be made a the routine home care rate. Payment at the respite rate is made when respite is provided at a MC or MCD certified hospital, SNF, hospice facility, or NF.

RESPITE CARE AND THE INPATIENT CAP The total number of inpatient days, including both general inpatient and inpatient respite care, used by Medicare beneficiaries who elected hospice coverage in a 12-month period in a particular hospice may not exceed 20 percent of the total number of days for which these patients had elected hospice care. (42 CFR 418.301(f))

RISK AREAS IN RESPITE Provision of respite outside of the specified MC guidelines as incentives for referrals or facility contracts is prohibited. To avoid: Ensure that documentation evidences the reason for caregiver relief. Ensure that contractual agreements do not contain language which may indicate a kickback or inducement arrangement. It may be difficult in some areas to secure a contract. Facilities may require the hospice to contract at a higher reimbursement than the Medicare per diem.

FEDERAL REGULATIONS AS RELATED TO THE RESPITE LEVEL OF CARE

COVERED SERVICES Subpart F Covered Services ξ418.202 Covered Services. (e) Short-term inpatient care provided in a participating hospice inpatient unit, or a participating hospital or SNF, that additionally meets the standards in 418.202 (a) and (e) regarding staffing and patient areas. Services provided in an inpatient setting must conform to the written plan of care. Inpatient care may be required for procedures necessary for pain control or acute or chronic symptom management. Inpatient care may also be furnished as a means of providing respite for the individual s family or other persons caring for the individual at home. Respite care must be furnished as specified in 418.98(b). Payment for inpatient care will be made at the rate appropriate to the level of care as specified in 418.302.

PAYMENT PROCEDURES ξ418.302 Payment procedures for hospice care. (3) Inpatient respite care day. An inpatient respite care day is a day on which the individual who has elected hospice care receives care in an approved facility on a short-term basis for respite. (e) The intermediary makes payment according to the following procedures: (5) Subject to the limitations described in paragraph (f) of this section, on any day on which the beneficiary is an inpatient in an approved facility for inpatient care, the appropriate inpatient rate (general or respite) is paid depending on the category of care furnished. The inpatient rate (general or respite) is paid for the date of admission and all subsequent inpatient days, except the day on which the patient is discharged. For the day of discharge, the appropriate home care rate is paid unless the patient dies as an inpatient. In the case where the beneficiary is discharged deceased, the inpatient rate (general or respite) is paid for the discharge day. Payment for inpatient respite care is subject to the requirement that it may not be provided consecutively for more than 5 days at a time. Payment for the sixth and any subsequent day of respite care is made at the routine home care rate.

PAYMENT PROCEDURES (CONTINUED) (f) Payment for inpatient care is limited as follows: (1) The total payment to the hospice for inpatient care (general or respite) is subject to a limitation that total inpatient care days for Medicare patients not exceed 20 percent of the total days for which these patients had elected hospice care. (2) At the end of a cap period, the intermediary calculates a limitation on payment for inpatient care to ensure that Medicare payment is not made for days of inpatient care in excess of 20 percent of the total number of days of hospice care furnished to Medicare patients. Only inpatient days that were provided and billed as general inpatient or respite days are counted as inpatient days when computing the inpatient cap. (3) If the number of days of inpatient care furnished to Medicare patients is equal to or less than 20 percent of the total days of hospice care to Medicare patients, no adjustment is necessary. Overall payments to a hospice are subject to the cap amount specified in Sec. 418.309. (4) If the number of days of inpatient care furnished to Medicare patients exceeds 20 percent of the total days of hospice care to Medicare patients, the total payment for inpatient care is determined in accordance with the procedures specified in paragraph (f)(5) of this section. That amount is compared to actual payments for inpatient care, and any excess reimbursement must be refunded by the hospice. Overall payments to the hospice are subject to the cap amount specified in Sec. 418.309. (5) If a hospice exceeds the number of inpatient care days described in paragraph (f)(4), the total payment for inpatient care is determined as follows: (i) Calculate the ratio of the maximum number of allowable inpatient days to the actual number of inpatient care days furnished by the hospice to Medicare patients. (ii) Multiply this ratio by the total reimbursement for inpatient care made by the intermediary. (iii) Multiply the number of actual inpatient days in excess of the limitation by the routine home care rate. (iv) Add the amounts calculated in paragraphs (f)(5)(ii) and (iii) of this section.