CMS is concerned about hospice over utilization and hospice underutilization of the general inpatient (GIP) level of care. CMS wonders if hospices are providing access to all four levels of hospice care (routine home care, general inpatient care, respite care and continuous home care) when it sees that some hospices have billed very little or no GIP care during a specified time period. On the other hand, CMS wonders if the GIP level of care is being properly utilized when it sees that some hospices have billed significantly more GIP days of care than their peers. 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:
- A Medicare-certified hospice that meets the conditions of participation for providing inpatient care directly as specified in §418.110.
- 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:
- Short-term care
- 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.”
Sounds simple, right? Not so. Short-term care is not defined, but GIP care for more than five consecutive days is considered long. According to CMS data, the average length of stay for GIP between 2010 and 2012 was 5.7 days with the median being 4 days. This is not to say that GIP should not be shorter or longer as the length of stay should be based on the patient’s condition.
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
- Interventions used to address the needs
- 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 more clearly document the effectiveness of the interventions and the patient’s progress toward goals. The most difficult GIP component to document seems to be why the interventions cannot be delivered in another setting. For instance, one of the acceptable reasons for a general inpatient level of care can be utilized is 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. it is frequent 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. There may be exceptions to this, but in general, it is reasonable to expect to see this. When documentation indicates that a patient has been transferred to a GIP level of care for pain and symptom management but there is no documentation explaining the specific symptom(s) and pain, and what has been done to address them in the home setting, payment is not supported. For example, good documentation would indicate that the patient was experiencing pain not relieved by 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 should be in the documentation.
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 situation 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 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 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 download the tool from your Alliance member dashboard. If you would like access to this tool along with all of our Alliance member downloads click here to learn more.