CMS continues to be concerned about hospice over utilization and hospice underutilization of the general inpatient (GIP) level of care. Are hospices providing access to all four levels of hospice care (routine home care, general inpatient care, respite care and continuous home care)? The data shows that some hospices only billed very little or no GIP care during a specified time period while other hospices billed significantly more GIP days of care than their peers during the same time period which, appropriately raises the question: Is the hospice GIP level of care being properly utilized? So, what are the requirements and how should GIP be utilized?
First, GIP is not an optional level of care. Hospices must be able to deliver GIP to patients who qualify for it. This means hospices must either provide it directly in their own hospice inpatient unit or they must contract with one of the other acceptable facilities:
1. A Medicare-certified hospice that meets the conditions of participation for providing inpatient care directly as specified in §418.110.
2. A Medicare-certified hospital or a skilled nursing facility that also meets the standards specified in §418.110(b) and (e) regarding 24-hour nursing services and patient areas.
Second, the hospice should ensure that it is offering and utilizing GIP when it is appropriate. CMS specifies that GIP care is:
1. Short-term care
2. To provide pain and symptom management that cannot be accomplished in another setting.
In addition to the above, CMS states “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.”
Because GIP is billed on a per diem basis, each day of care must support the need for GIP. This is the key to proper utilization. Therefore, the following should be included in documentation:
• The pain/symptom management needs being addressed
− The Interventions used to address the needs
− The Patient’s response to the interventions and progress toward goals
• Why the interventions cannot be provided in the home setting
• Discharge planning
Since GIP is to be short-term, discharge planning should begin right away. There is no set number of days a hospice has to plan for a patient’s discharge from this level of care. Most hospices do not have difficulty documenting the interventions being implemented but do sometimes need to document the effectiveness of the interventions and the patient’s progress toward goals more clearly. The most difficult GIP component within the documentation seems to be “why” the intervention(s) cannot be delivered in another setting. For instance, one of the acceptable reasons for the use of the general inpatient level of care can be medication adjustment. This can be done in other settings, of course, so the hospice documentation must indicate why the GIP level of care is necessary for the medication adjustment, i.e., the patient requires the medication frequently and the skills of a nurse are needed for observation and assessment.
Unless there is a procedure that needs to be performed that cannot be performed in any other setting, it would be expected that hospice documentation would describe the event(s) leading up to the decision to utilize GIP. When a patient is transferred to the GIP level of care for pain and/or management of other symptoms(s) but there is no documentation explaining the specific pain and/or symptom(s), and what has been done to address them in the home setting, payment is not supported. An example of good documentation to support the need to utilize the GIP level of care may include:
The patient was experiencing pain not relieved by current medication. A call was made to the on-call nurse who instructed additional medication be given. The caregiver called back to indicate that the pain was still not controlled. The nurse made a visit and observed the patient in severe pain for which she was able to use a medication from the emergency kit. The new medication lessened but did not resolve the pain and the patient soon was in severe pain again. The patient also became nauseous and started vomiting. The nurse contacted the physician who instructed the nurse to transfer the patient to GIP for pain management. Specifics of the medications tried and the patient’s response to the medication provided support for the need of the GIP level of care.
Once GIP is initiated, there should be daily documentation indicating what symptoms are being addressed, the interventions used, and the patient’s response. Continuing with the same example above, the documentation during GIP should include the patient’s pain rating, the severity of the nausea, what medications were administered and the patient’s response to the medications. It may take several days to find the right mix and route of medications and each day’s documentation should reflect the continued need for GIP. Simply documenting the medications provided and that the patient’s pain gradually decreased to an acceptable level is not sufficient. Why this could not be accomplished in another setting should be clear – either because it is obvious from the type/frequency of care provided or because it is stated in the documentation. HPS has seen partial claim denials under medical review when the documentation does not support all the days billed for the GIP level of care. Typically, the uncontrolled symptoms are resolved within 3-5 days then the documentation only supports the continued administration of the medication required to control the symptom(s) without any new medications/interventions or changes in the current medication to support the continued need for the GIP level of care.
The Palmetto GBA MAC released a GIP initiative in 2019 to determine potential causes for extended lengths of stay for the GIP level of care with letters sent to all providers and education that included teleconferences for the use of the GIP level of care. Palmetto GBA identified three primary topics to help hospice providers avoid long GIP lengths of stay: Evaluation, Discharge Planning, and Documentation. This initiative provided hospices the appropriate use of the hospice GIP level of care. The consequences when the documentation does not support the need for this higher level of care is claim denial under medical review.
Key areas for each topic identified included:
- Evaluation – The patient must meet the criteria for the GIP level of care with uncontrolled pain or symptom(s) that can not be provided in any other setting. And the GIP level of care must be provided in a Medicare approved setting.
- Discharge Planning – Discharge planning begins on admission and continues throughout the GIP stay. The patient may remain in a facility, but Medicare will not pay for the GIP care days if the medical records does not indicate a clear need for the GIP level of care. GIP is not intended to be custodial or residential, once the patient’s symptoms are stabilized or pain is managed, he or she should return to the hospice Routine level of care.
- Documentation – Palmetto GBA included 5 recommendations for hospice providers to help ensure the documentation supports the GIP level of care:
- Describe the services provided.
- Identify the precipitating event that led to GIP status.
- Describe failed attempts to control symptoms that occurred prior to admission.
- Identify specific symptoms that are being actively addressed.
- Document care that the patient’s caregiver cannot manage at home.
We are seeing an increase in medical reviews targeting claims for the GIP level of care and until the pause of the Targeted Probe and Educate (TPE) audits, due to the public health emergency for the COVID-19 pandemic, some of the Medicare MACs specifically targeted hospice providers who consistently billed the GIP level of care for greater than 5 days. It is imperative that your hospice program provide access to the GIP level of care as required and when the higher level of care is needed the documentation MUST support the need for GIP to avoid denials under medical review.
HPS Alliance Members now have access to a Hospice General Inpatient Audit Tool, as part of their membership, which includes the GIP regulatory requirements and provides examples for the types of situations for which GIP can be utilized. Click here to access to this tool along with all of our Alliance member downloads. If you are not a member, click here to learn more.