Hospice Conundrums (Part 1): Demystifying GIP, Ensuring Appropriate Use, Documentation, and PaymentErin Boyd, MD General inpatient hospice (GIP) is a Medicare benefit also covered by many Medicaid and commercial insurances that is frequently misunderstood by physicians, hospitals, and families. The use of GIP varies widely across hospices, and the Office of Inspector General just recently announced in June 2023 that GIP is a priority audit area. Given this, understanding the key components of GIP, appropriate use, reimbursement, and documentation is essential. Importantly, although the pneumonic GIP is for “general inpatient hospice,” GIP is an entirely different service than inpatient level of care. GIP is actually one of four types of benefits that all hospice agencies must provide for patients enrolled in hospice including: 1.routine home care, 2.continuous home care, 3.general inpatient care (GIP), and 4.inpatient respite care for relief of the patient’s caregivers. GIP can be offered in a Medicare participating hospital, skilled nursing facility, or hospice inpatient facility, and the purpose of GIP is to provide short term relief of uncontrolled symptoms that cannot be managed in an alternative setting. Examples of when GIP may be appropriate include aggressive treatment for pain control, uncontrolled nausea/vomiting, frequent seizures, severe agitation/anxiety related to end stage process, and symptom management that requires frequent skilled nursing observation or intervention. GIP is not intended for respite care/caregiver relief, to be automatically used when end-of-life care is needed for the imminently dying patient (the patient must have clear need for skilled nursing), or for patients on hospice who need more general supervision for reasons other than aggressive symptom management (falls, safety). Given GIP is an entirely different level of care than inpatient level of care, the two-midnight rule does not apply, and neither do other notices such as the Important Message from Medicare (IMM) or HINN letters. GIP also does not pay by DRG but rather per diem. Interestingly, though it is not considered “inpatient” care, GIP midnights in a hospital DO count towards the “3 midnights” needed for SNF per the Medicare Benefit Policy Manual Chapter 9 should a patient initially receiving GIP ultimately revoke hospice and need to be discharged to SNF. To initiate GIP services, a patient must already be enrolled in hospice. The hospice physician employed by or under contract with the hospice is responsible for evaluating the patient, ensuring that medical necessity for GIP is met, and ensuring that there is daily documentation supporting why ongoing GIP care is needed. The desire of a non-hospice attending to “Admit to GIP” is not sufficient to begin GIP services as the hospice and managing team must agree that GIP is needed. Specifically, documentation should include the circumstances that led to the need for GIP (failed attempts to achieve symptom control), and daily updates regarding what symptoms are being addressed, the patient’s response to intervention, progression towards goals, discharge planning, and why the symptoms cannot be addressed in a different setting (home, respite care, etc.). Documentation of “why” interventions being performed cannot occur in a lower acuity setting is critical and may relate to frequent medication adjustment clearly requiring constant nursing supervision to assess response. With regards to payment and billing for GIP, a hospice pays the hospital for GIP services after the hospice submits a claim directly to Medicare part A with code 0656 and the hospice agency gets paid. Per the final rule for fiscal year 2024 (CMS-1787-F), base payment rate per diem for GIP for fiscal Year 2024 is $1142.20, and the absolute dollar cap a hospice can receive cannot be greater than the total number of Medicare patients cared for by the hospice multiplied by $33,494.01. If documentation does not support the need for GIP level of care, hospices could be subject to adverse audit outcomes or receive payments at a non-GIP rate and have difficulty paying the hospital. Additionally, should there be a case where a patient was appropriate for GIP but now does not meet requirements and family is declining an appropriate alternative level of care, an ABN could be issued. Further noted is that GIP services (as with all other hospice services) for Medicare part C beneficiaries (Medicare Advantage), are always paid for by Medicare part A per 42 CFR Part 417.585, Subpart P. Billing for hospice/GIP to Part A for either a Medicare FFS or a Medicare Advantage recipient starts with a notification of election filled within 5 days of hospice election assuming the patient clearly meets hospice enrollment eligibility with a documented life expectancy of 6 months or less. A hospice beneficiary can change hospices once per benefit period (either the initial 90-day or subsequent 60-day periods) or revoke hospice at any time. When hospice is revoked, a patient who had been on Medicare Advantage coverage prior to enrolling in hospice is still covered by Medicare A/B rather than the Medicare Advantage plan until the end of the month, after which Medicare Advantage would assume responsibility for payment. In sum, understanding the nuances of GIP with regards to appropriateness of use and required documentation is becoming increasingly important as GIP comes under increased auditor scrutiny. Remembering that GIP is entirely separate from inpatient care despite “inpatient” being in its name, and that Medicare Advantage hospice benefits including GIP are paid just like Medicare FFS through part A is critical. Stay tuned for further hospice/end-of-life conundrums related to patients needing services not related to hospice, revocation of hospice, and impact of GIP/care of end of life patients on quality metrics in further newsletters! Dr Boyd is Associate Chief Medical Officer at Sound Advisory Services |