It is 9pm. A hospice patient at home has uncontrolled pain and escalating agitation, the daughter who has been caring for her is exhausted, and the on-call nurse thinks the patient needs someone at the bedside through the night. That is the situation hospice continuous home care exists for. It is also the level of care many hospices are least prepared to staff and most likely to document in a way that does not survive review.
This guide sets out what qualifies, the counting rules, how billing works in 15-minute units, two worked examples, and a staffing approach that holds up at 9pm.
What Qualifies as Hospice Continuous Home Care
Under 42 CFR 418.204(a), nursing care may be covered on a continuous basis for as much as 24 hours a day during periods of crisis, as necessary to keep the patient at home. A period of crisis is one in which the patient requires continuous care to achieve palliation and management of acute medical symptoms. Aide and homemaker services may also be provided, but care during these periods must be predominantly nursing care.
The Medicare Benefit Policy Manual, Chapter 9, section 40.2.1 adds practical detail:
- A caregiver who has been providing a skilled level of care and becomes unwilling or unable to continue can precipitate a crisis, because a nurse may be needed to replace that care.
- Continuous home care can be provided where a patient lives in a long-term care facility, but not in an inpatient facility such as a hospice inpatient unit, hospital or SNF.
- It is not respite. Respite is a separate, inpatient level of care.
Continuous home care is rare. MedPAC's March 2026 hospice chapter reports that routine home care accounted for 98.8% of Medicare-covered hospice days in 2024. Because it is rare, staff rarely practice the rules, and the rules are exact.
The Counting Rules
From the manual and 42 CFR 418.302:
- Minimum 8 hours of care in a day, where the day runs midnight to midnight. The hours do not need to be consecutive; the manual's example is 4 hours in the morning and 4 in the evening. Fewer than 8 hours is paid as routine home care.
- More than half the hours must be nursing, by an RN, LPN or LVN. A nurse practitioner providing care that an RN, LPN or LVN would otherwise provide counts as nursing.
- Only direct patient care counts. Documentation, revising the plan of care and supervising aides or homemakers do not count. Neither do social worker, chaplain or counselor services, although they would be expected during a crisis if warranted.
- All nursing and aide hours are counted. If aide hours exceed nursing hours, the day is paid as routine home care. The manual says hospices cannot discount any portion of the hours provided in order to qualify.
- Overlapping hours of a nurse and an aide both providing direct care count separately, but total paid hours cannot exceed 24 in a day.
Worked Examples
From the manual. A nurse spends 2 hours teaching the family to give IV medication, returns for 1 hour in the evening, an aide provides 3 hours, and the nurse spends 2 hours phoning physicians, ordering medications, documenting and revising the plan of care. CMS's determination: despite 8 hours of service, this is not continuous home care, because 2 of the 8 hours were not direct patient care.
A midnight-boundary example (illustrative). The crisis starts at 2pm.
Day 1, 2pm to midnight: - LPN 2pm to 6pm: 4 hours - Aide 6pm to 10pm: 4 hours - RN 10pm to midnight: 2 hours - Total 10 hours, nursing 6 of 10. Qualifies.
Day 2, midnight to noon: - RN midnight to 4am: 4 hours - Aide 4am to 10am: 6 hours - LPN 10am to noon: 2 hours - Total 12 hours, nursing 6 of 12. Exactly half is not more than half, so the day does not qualify and is paid as routine home care.
The fix is in the grid, not the note. Had the LPN arrived at 9am and the aide left at 9am, nursing would be 7 of 12. Check every calendar day separately, and check it before the shifts are worked.
Billing in 15-Minute Units
The Medicare Claims Processing Manual, Chapter 11, section 30.1 sets the billing mechanics:
- Revenue code 0652, with a separately dated line for each day of continuous home care.
- Units in 15-minute increments, rounded to the nearest increment. Payment applies when 32 or more units, the 8-hour minimum, are billed for the day.
- Do not bill shifts or non-direct increments such as meal breaks, report or staff education.
The rate is set per 24 hours and divided by 24 for an hourly rate. For FY 2027, per CMS Transmittal 13976, the national continuous home care rate is $1,726.16 for a full 24 hours, or $71.92 an hour, for hospices meeting quality reporting requirements. The labor portion is wage-adjusted at a 75.2% labor share. Day 1 above, at 10 hours or 40 units, pays 10 × $71.92 = $719.20 before wage adjustment. The FY 2027 hospice payment rates guide shows how to apply your wage index.
A Staffing Model That Works at 9pm
Hospices must make nursing services routinely available on a 24-hour basis, 7 days a week, under 42 CFR 418.100(c)(2). Continuous home care asks more: hours of nursing at one bedside, often overnight, on no notice. A workable model has five parts:
- 1.A written crisis trigger. Criteria for when the on-call nurse escalates to continuous home care, and who approves it, so the decision is clinical and consistent.
- 2.A continuous care roster. RNs and LPNs who have agreed in advance to take continuous care shifts, with availability by night and weekend. Per diem nurses are often the backbone.
- 3.A shift grid template that totals nursing and aide hours per calendar day and flags any day where nursing is not more than half, or total hours are under 8.
- 4.Pre-matched staff. Continuous care staff need the plan of care, medication profile and symptom history before arriving. The scheduling and matching guide covers why availability alone is not a match.
- 5.A daily reassessment. Every day, the nurse documents whether the crisis continues. When symptoms are controlled, the patient returns to routine home care. If symptoms cannot be managed at home, general inpatient care may be the right level instead.
Common Errors That Turn CHC Into Routine Home Care
- Counting the shift, not the care. An 8-hour nurse shift that includes report, charting and a meal break is not 8 hours of direct care. Record time in and out for direct care, in 15-minute increments.
- Ignoring the midnight line. A 12-hour overnight shift splits across two calendar days, and each day must meet the 8-hour minimum and the nursing majority on its own.
- Aide-heavy grids. It is often easier to find an aide than a nurse at 2am. If aide hours exceed nursing hours on a day, the day is routine home care, and you cannot leave aide hours off the claim to fix it.
- Continuing after the crisis. Once symptoms are managed and the nurse is providing ordinary monitoring, the crisis has ended. Continuing CHC "just in case" is the pattern reviewers look for.
- Using CHC as respite. If the real need is caregiver relief, the level of care is respite, which is inpatient and limited to no more than five consecutive days at a time under 42 CFR 418.204(b).
Documentation Reviewers Look For
- The acute symptoms that define the crisis, in clinical terms, with times.
- Interventions and the patient's response, hour by hour or visit by visit.
- Time in and out for every person providing direct care, by discipline.
- The plan of care update that ordered continuous care.
- Why the crisis is continuing, written each day, and when it ended.
A note that says "patient in crisis, CHC continued" for three days is a denial waiting to happen. A note that shows pain scores, doses, agitation episodes and the reason a nurse is still needed is the record that holds up.
Where Systems Help
The hard parts of continuous home care are the grid and the clock: who is available tonight, whether every calendar day clears the nursing majority, and whether time is recorded in usable increments. Nuraflow is being designed so that scheduling and care matching supports visit, shift and on-call scheduling with credential checks, within its hospice workflows.
This article is general information, not billing or clinical advice. Confirm level-of-care decisions and billing practices with your medical director, compliance officer and MAC.