Hospice agencies must correctly assign and document the appropriate level of care for every patient based on clinical needs. The four Medicare hospice levels of care are:
These levels are regulated under the Centers for Medicare & Medicaid Services (CMS) hospice benefit. Surveyors and auditors closely review whether each level of care is clinically justified, properly documented, and consistently supported throughout the patient record.
Incorrect use of levels of care is one of the most common causes of survey deficiencies, claim denials, and audit recoupments.
Why Hospice Levels of Care Are a High-Risk Area
Each level of care has specific eligibility criteria. Agencies must demonstrate that:
The patient met criteria at the time of service
Documentation supports the level billed
Care was delivered consistent with regulatory requirements
Surveyors are not only checking what level was billed. They are asking:
“Was this the correct level of care based on the patient’s condition, and is it fully supported by documentation?”
Routine Home Care (RHC)
What It Is
Routine Home Care is the most common level of hospice care, provided when the patient’s symptoms are stable and can be managed in the home or residential setting.
What Surveyors Look For
Surveyors expect clear documentation showing that the patient:
Is terminally ill with a prognosis of 6 months or less
Has symptoms that are manageable without continuous or inpatient care
Receives care consistent with the plan of care
Key Documentation Requirements
Interdisciplinary Group (IDG) notes supporting ongoing care
Skilled nursing and/or therapy interventions
Symptom management documentation
Evidence of decline or disease progression
Common Deficiencies
Lack of documentation showing ongoing decline
Generic or repetitive visit notes
Care that appears custodial rather than skilled
Failure to update plan of care
General Inpatient Care (GIP)
What It Is
GIP is the highest level of hospice care, used for short-term management of acute symptoms that cannot be controlled in another setting.
What Surveyors Look For
Surveyors expect documentation showing:
Acute symptom crisis (e.g., pain, dyspnea, agitation)
Symptoms cannot be managed in home setting
Need for intensive nursing and medical interventions
Required Elements
Daily physician involvement
Frequent skilled nursing interventions
Clear documentation of symptom severity
Evidence that lower levels of care were insufficient
Common Deficiencies
Lack of documentation supporting acute symptom crisis
Prolonged GIP stays without justification
Minimal physician involvement
Notes that do not reflect intensive care
Continuous Home Care (CHC)
What It Is
Continuous Home Care is provided during periods of crisis in the home setting, requiring extended nursing care.
What Surveyors Look For
CHC must demonstrate:
Documentation Requirements
Detailed hourly documentation of care
Skilled nursing interventions
Evidence of symptom management
Documentation showing crisis resolution
Common Deficiencies
Failure to meet minimum hourly requirements
Documentation dominated by aide services instead of nursing
Lack of evidence of crisis
Poorly documented start and end of CHC
Inpatient Respite Care
What It Is
Respite care provides short-term relief for caregivers by temporarily admitting the patient to an inpatient setting.
What Surveyors Look For
Surveyors expect:
Documentation showing caregiver need for relief
Planned and temporary nature of stay
Duration not exceeding regulatory limits (typically 5 days)
Documentation Requirements
Caregiver request or need
Admission and discharge documentation
Continuity of care planning
Common Deficiencies
Lack of documentation supporting caregiver need
Respite used for reasons unrelated to caregiver relief
Exceeding allowable length of stay
Cross-Level Documentation Expectations
Regardless of level of care, surveyors expect consistency across all records.
Documentation must align across:
Red Flags Across All Levels
Surveyors often identify patterns that trigger deeper review:
Frequent level-of-care changes without clear justification
Documentation that appears templated or cloned
Lack of symptom progression or change
Inconsistent documentation between disciplines
High-Risk Audit and Survey Triggers
Hospice agencies are at higher risk when:
GIP is used for extended periods without acute symptoms
CHC does not meet hourly requirements
RHC documentation does not demonstrate decline
Respite care is used inappropriately
These patterns often lead to:
Claim denials
Medical review audits
Survey deficiencies
Strategies to Ensure Compliance
Strengthen Documentation
Agencies should ensure:
Documentation clearly supports level of care
Notes reflect real-time clinical conditions
Interventions are specific and individualized
Implement Internal Audits
Routine audits should focus on:
Level-of-care justification
Documentation consistency
Duration of higher levels (GIP, CHC)
Train Clinical Staff
Staff must understand:
Monitor High-Risk Cases
Focus on:
Best Practices for Survey Readiness
Agencies that perform well during surveys:
Maintain strong IDG documentation
Align documentation across all disciplines
Conduct mock surveys
Monitor level-of-care utilization trends
Ensure physician involvement is documented
Conclusion
Hospice levels of care are one of the most scrutinized areas during surveys and audits. Each level must be supported by clear, consistent, and clinically meaningful documentation.
Agencies that understand the intent behind each level of care and implement strong documentation and audit systems are best positioned to maintain compliance, reduce risk, and succeed during regulatory review.
References
CMS Hospice Benefit Overview
https://www.cms.gov/medicare/coverage/hospice-benefit
Medicare Benefit Policy Manual – Hospice (Chapter 9)
https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/bp102c09.pdf
CMS Hospice Conditions of Participation (42 CFR §418)
https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418
CMS Program Integrity Manual (Pub. 100-08)
https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/pim83c03.pdf
