HCPCS code T2043 – Hospice continuous home care billing

Key takeaways

HCPCS code T2043 bills hospice continuous home care per hour on state Medicaid claims, and Medicare does not pay T-codes.

A continuous home care day needs at least 8 hours of direct care between one midnight and the next.

More than half of those hours must come from licensed nurses, or the day pays at the routine rate.

Medicaid hospice rates follow Medicare’s, and the FY 2027 national base is $71.95 an hour before wage adjustment.

Check your state’s unit rule, because Ohio bills one T2043 unit per hour while Medicare’s revenue code 0652 counts 15-minute units.

HCPCS code T2043 pays for hospice crisis care by the hour

HCPCS code T2043 is the Level II code for hospice continuous home care, billed per hour. It took effect on October 1, 2003. It also sits in the T-code range reserved for state Medicaid agencies, so Medicare doesn’t pay it.

Continuous home care is the most intensive hospice care a patient can receive without moving to a facility. A nurse stays with the patient through a medical crisis, often with an aide or homemaker alongside. The aim is to control symptoms at home, so the patient avoids a transfer to an inpatient bed.

Medicaid pays hospices at four levels of care. T2043 is the only one billed by the hour, while the other three pay a flat daily rate. That hourly unit is what makes this code easy to get wrong.

Continuous home care starts with a documented crisis

Every T2043 hour has to trace back to a crisis. Under 42 CFR 418.204, nursing care can be covered continuously, for up to 24 hours a day, during a period of crisis. A crisis is a period when the patient needs continuous care to manage acute medical symptoms.

The CMS Medicare Benefit Policy Manual, chapter 9 sets the detailed rules, and state Medicaid programs build on them. It names a practical trigger, too. When a caregiver who has been giving skilled care can no longer do it, a nurse may be needed to fill that role.

Situations in the CMS examples that can support a crisis day include:

• Uncontrolled pain or vomiting that needs frequent medication changes.
• New seizures, or breathing that deteriorates quickly near the end of life.
• A family caregiver who has been giving skilled care and can no longer continue.

Location matters as well. Continuous home care can happen in the patient’s own home, including a long-term care facility where they live. It cannot be billed during a stay in a hospital, a skilled nursing facility, or a hospice inpatient unit.

Exhaustion alone isn’t a crisis. In one CMS example, an 80-year-old caregiver needs help with bathing, meals and walking. That patient fits inpatient respite care, not continuous home care.

The 8-hour rule and a nursing majority decide each day

Once a crisis is documented, two tests decide whether the day pays at the continuous rate. The hospice must provide at least 8 hours of direct care in a 24-hour day that begins and ends at midnight. The hours don’t need to be back to back, so 4 in the morning and 4 at night count.

Next, the care must be predominantly nursing. More than half of the hours must come from a registered nurse (RN), licensed practical nurse (LPN) or licensed vocational nurse (LVN). Aides and homemakers can add hours, but they can’t make up the majority.

Several kinds of time never count toward the total:

• Charting, revising the plan of care, and supervising aides.
• Social worker, chaplain and counselor time, even though those visits are expected.
• Meal breaks, shift handoffs, staff education, and travel.

Fall below 8 hours and the day pays as routine home care. The same happens when aide hours outnumber nursing hours. Hospices also cannot drop aide hours from the count to reach a nursing majority.

A worked example from the CMS manual

Here is how one day from the CMS guidance adds up. A patient near death has worsening pain, vomiting and air hunger.

Nursing made up 6 of the 10 hours, so the day qualifies. Swap the roles, with 3 nursing hours and 6 aide hours, and it wouldn’t. The chart below puts both days side by side, with the units each one bills.

T2043 belongs to a five-code hospice family

With the daily rules clear, it helps to see where T2043 sits. Medicaid programs that bill with HCPCS Level II codes use five hospice T-codes. Four of them match a Medicare revenue code. Chapter 11 of the Medicare Claims Processing Manual lists those revenue codes.

Each day carries one level of care. On a crisis day you bill T2043, not T2042 as well. Room and board under HCPCS code T2046 is the exception, because it is an add-on for nursing facility residents. Federal law sets that payment at no less than 95% of the facility’s Medicaid daily rate.

Watch out for T2041, too. It sits next door numerically, but it describes self-directed supports brokerage under a waiver, billed per 15 minutes. It isn’t a hospice code at all.

Medicaid’s T2043 rate follows Medicare’s hourly math

Medicaid hospice rates are built on the Medicare rates, which CMS updates every October. The FY 2027 Medicaid hospice rate letter sets the floor states must pay from October 1, 2026.

• Full continuous home care rate: $1,726.83 for 24 hours of care.
• Hourly rate: $71.95, the full rate divided by 24.
• Without quality data: $69.14 an hour, after the 4-percentage-point reduction.

These are national base rates, not what lands in your account. States adjust the wage portion by the hospice wage index, and for continuous home care that follows where the patient lives. States may also pay above the minimum, so your state fee schedule is the final word.

Patients covered by both programs follow a different path. Medicare pays the hospice benefit first, and Medicaid then pays nursing facility room and board. In that case the crisis day goes on the Medicare claim as revenue code 0652, not T2043.

Hours or 15-minute units? The conversion that trips claims

This is where clean crisis care turns into a rejected claim. Medicare reports continuous home care in 15-minute increments, while T2043’s descriptor says per hour. A quick Q&A shows how the two fit.

How does Ohio count it? Ohio Administrative Code 5160-56-06 bills T2043 at one unit per hour. It also requires a minimum of eight hours a day.

How does Medicare count it? The same 8-hour floor is 32 units on revenue code 0652. Units round to the nearest 15-minute increment, not up to the next hour.

Do any states add modifiers? Yes. MassHealth’s hospice manual pairs T2043 with modifier TN for care outside the county where the hospice is located.

So what goes on the claim? For the 10-hour day above, that means 10 units of T2043 in Ohio, or 40 units of 0652 on Medicare. Read your state’s hospice billing instructions before converting units.

How a T2043 claim moves from crisis to payment

With the unit settled, the claim itself follows a predictable path. Each step depends on the one before it.

1. Confirm the election. The patient must have elected the Medicaid hospice benefit, backed by a physician’s certification of terminal illness. Adults waive other Medicaid treatment for the terminal condition, but patients under 21 can keep curative care.
2. Update the plan of care. The interdisciplinary group orders continuous home care for the crisis and records the symptoms it targets.
3. Log every discipline’s time. Each nurse, aide and homemaker records start and stop times for direct care only.
4. Total the day at midnight. Confirm at least 8 hours, with nursing above half. If either test fails, bill routine home care instead.
5. Code and convert. Apply T2043 with the units and any modifiers your state requires.
6. Step back down. When the crisis resolves, the plan of care returns to routine home care, and so does the claim.

T2043 documentation must prove the crisis behind the hours

Continuous home care draws close review. CMS lists continuous home care medical necessity as an approved Recovery Audit topic. A chart that shows hours but no crisis is the weakest file a reviewer can open.

A record that holds up usually contains:

• The acute symptoms behind the crisis, described in clinical terms, with the time they started.
• The plan of care update that ordered continuous home care.
• Start and stop times for each nurse, aide and homemaker, with the care given in each block.
• A daily total that separates nursing hours from aide and homemaker hours.
• Notes on how the patient responded, and when the crisis ended.

Shift schedules don’t count as documentation. CMS states that continuous home care billing should reflect direct patient care, not staff working hours.

Common T2043 mistakes that turn a crisis day into a routine day

Most T2043 problems come from the same handful of habits. Each one below either cuts the payment to the routine rate or sends the claim back.

When the same mistake keeps coming back, treat it as a process problem, not a one-off. Our guide to denial management in healthcare shows how to trace each denial to its cause.

Before you submit: A quick T2043 checklist

Run through these points on every crisis day, so the claim leaves your desk as a clean claim.

• The hospice election and terminal illness certification are on file and current.
• The plan of care orders continuous home care for this crisis.
• The day totals 8 or more hours of direct care.
• Nursing hours are more than half of the total.
• The patient was at home or in their long-term care residence, not an inpatient bed.
• Units match your state’s rule, hourly or otherwise.
• Any state modifier, such as an out-of-county modifier, is attached.
• No other level of care is billed for the same day.

How Pabau keeps crisis-day hours and notes in one record

During a crisis, time records often live in three places. Nurses chart in one system, aides fill in paper logs, and billing rebuilds the day from both. When those records disagree, the claim is hard to defend.

Pabau, the clinical records and practice management platform we build, keeps visits, timed notes and signed forms on the patient’s record. Billing staff can then check the hours against the chart before coding. Our claims management tools also confirm that required claim fields are complete before submission.

Keep crisis-day records ready for billing

Pabau keeps visits, timed clinical notes and signed forms on one patient record. Your billing team can match T2043 hours to the chart before the claim goes out.

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Conclusion

T2043 rewards hospices that can prove three facts for each day: a crisis, at least 8 hours, and a nursing majority. Miss one, and the day pays at the routine rate no matter how hard the team worked.

Your state manual decides the unit, so read it before the first crisis, not after the first rejection. Then make timed, discipline-by-discipline notes the standard for every continuous home care shift. Book a demo to see how Pabau keeps visit notes, signed forms and billing on one patient record.

Continue your research

Want claims that pay on the first pass? What is a clean claim in medical billing? explains what a payer checks before it accepts a claim.

Preparing for a billing audit? Medical billing compliance explains the documentation and coding standards auditors check first.

Want steadier cash flow from Medicaid claims? What is revenue cycle management walks through each stage from eligibility to payment posting.

New to HCPCS and claim forms? What is medical billing covers how codes, claims and payers fit together.

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