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General Inpatient (GIP) Care is one of the four levels of care available to patients who elect the Medicare Hospice Benefit. GIP level of care is appropriate when the patient’s medical condition warrants a short-term inpatient stay for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings. This care must be provided in a Medicare participating hospital, skilled nursing facility (SNF) or hospice inpatient facility.

When may GIP level of care be appropriate?

  • Aggressive treatment to control pain
  • Sudden deterioration requiring intensive nursing intervention.
  • Uncontrolled nausea or vomiting.
  • Pathological fractures
  • Uncontrolled bleeding
  • Frequent seizures
  • Unmanageable respiratory distress
  • Severe agitated delirium/anxiety/agitation related to end-stage disease process.
  • Symptom management that requires frequent skilled nursing observation/intervention.

GIP level of care is based on a clinical need to manage an uncontrolled symptom that cannot be managed in another setting. Determine first, why GIP higher level of care now and how is the GIP level of care intervention different from the current level of care? Then continue to document clearly the ongoing need for the GIP level of care until a resolution is achieved.

1. Transfer documentation needs to include the detail reason for the GIP level of care and is key to providing medical reviewers with a clear understanding of the GIP admission.

  • Specifically what symptom is no longer manageable in the patient’s home setting?
  • What precipitating events led up to the Interdisciplinary Group’s (IDG) decision for the GIP level of care?
  • What interventions were implemented and ineffective in managing the uncontrolled symptom in the current setting?
  • Is all of this clearly documented in the patient’s chart?

2. Once the patient is admitted to GIP the hospice team must document each day the continued need for the GIP level of care that identifies the specific symptoms being managed. The documentation should always reflect working towards a lower level of care with discharge planning evident from the first day of the GIP admission.

  • What specific interventions were implemented? What was the patient’s response?
  • How many PRN medications were required in the last 24 hours to meet symptom control goals? Keep in mind PRN medications that are given routinely do not support the ongoing need for GIP.
  • Is there documentation of the education provided to the patient/family?
  • Does the documentation support discharge planning? The discharge plan may be anticipation of the patient’s death.

3. Transition to a lower level of care upon resolution of the crisis.

  • Document the reason for GIP level of care is resolved and the discharge plan.
  • Document updates to the patient plan of care.
  • Document transition to a lower level of care (Respite Level of Care may be required).

When is it NOT appropriate to use GIP level of care?

  • General Decline
  • End-of-life care
  • Patient actively dying
  • Caregiver breakdown
  • No available caregiver in the home
  • Fall risk and supervision needed

All hospice providers need to ensure audits are in place to review GIP documentation prior to billing the claim to ensure the documentation supports the level of care.

Additional references for the GIP level of care for the Medicare hospice benefit can be found within the Hospice Medicare Claims Processing Manual (section 30.1), the Hospice Medicare Benefit Policy Manual (section 40.1.5) and the State Operations Manual-Hospice CoP §418.108.

HPS Alliance members can access a GIP level of care audit tool here.