By Ellen Middendorf, MD- Medical Director of Hospice of Southern Illinois
General Inpatient Care, commonly referred to as GIP, is one of the four levels of available hospice care. As the name implies, this is hospice care provided to a patient in an inpatient setting. CMS allows this care to be provided only in a Medicare-certified hospice inpatient unit or facility, a Medicare-certified hospital, or a Medicare-certified skilled nursing facility, though the latter is less common. The hospice works with the inpatient medical team to coordinate services and manage symptoms. The caveat for this level of care is that it is defined as short-term care provided for a patient’s pain management or acute symptom control that cannot be managed in other settings. Therefore, GIP-level care may be provided at the end of an acute hospital stay. However, there must be a need for pain control and symptom management, which cannot be feasibly provided in the home setting at hospital discharge.
The Hospice Medical Director, in collaboration with the Interdisciplinary Team (IDT), ultimately determines if the patient’s clinical condition warrants this level of care. As has been noted, this level of care is designed for short-term intervention. The length of stay is individualized to the needs of the patient. There is no set limit for the number of days that a patient can remain under GIP care, but there must be daily documentation supporting this higher level of care as longer length of stays may come under scrutiny from CMS. The IDT must develop a discharge plan for the patient, even at the time of hospice inpatient admission, should the level of inpatient care no longer be necessary.
There is no specific disease, condition, or symptom that qualifies a patient to receive GIP care. The determinant is patient symptomatology. The following list identifies some possible patient status triggers that may justify General Inpatient Hospice care:
- Pain or symptom crisis not managed by changes in treatment in the current setting or that requires frequent medication adjustment and monitoring.
- Frequent need for evaluation and re-assessment by a physician and/or nurse.
- Intractable nausea and vomiting.
- Advanced open wounds require frequent treatment changes and close monitoring.
- Unmanageable respiratory distress.
- Severe, agitated delirium or acute anxiety with behaviors, secondary to end-stage disease process requiring intensive intervention.
- Sudden decline necessitating intensive nursing intervention.
- Pathological fractures require medication adjustments for pain control and multiple caregivers for repositioning patients.
CMS also gives direction as to when the GIP level of care is not appropriate. The following list summarizes this guidance.
- Not appropriate for the sole indication of imminent death or inability to survive transfer.
- Not intended to address unsafe living conditions in the patient’s home.
- Not intended for caregiver respite or lack of caregiver altogether.
- Not allowable after symptom crisis has resolved.
- Not appropriate when the patient and/or family refuse to leave inpatient care.
In these situations, complications arise when balancing appropriate patient care and CMS guidance. Due to the complexity of this aspect of hospice care, the Office of the Inspector General (OIG) has recommended to CMS that increased scrutiny be placed on this level of billing. This has resulted in increased oversight of hospice GIP claims and increased surveyor efforts to ensure that hospices meet care planning requirements. At Hospice of Southern Illinois, we pride ourselves on the high ethical standards upheld by our organization. We will always strive to provide the best possible care to our patients and families, regardless of the location and setting, but we will also ensure that our organization is following CMS regulations and being contentious stewards of our reimbursement funding. Our Interdisciplinary Team will work diligently with you to walk this difficult path.
Palmetto GBA General Inpatient Care webinar: Retrieved from https://event.on24.com/eventRegistration/console/EventConsoleApollo.jsp?&eventid=3850805&sessionid=1&username=&partnerref=&format=fhaudio&mobile=&flashsupportedmobiledevice=&helpcenter=&key=E46A8EB79EF7F80BFFFB40A236C4B9B2&newConsole=true&nxChe=true&newTabCon=true&consoleEarEventConsole=false&text_language_id=en&playerwidth=748&playerheight=526&eventuserid=561202654&contenttype=A&mediametricsessionid=485285290&mediametricid=5417892&usercd=561202654&mode=launch
NHPCO Compliance Tip Sheet: Managing General Inpatient Care for Symptom Management, Revised February 2022