Home Health & Hospice Week

Make sure each GIP day can stand on its own.

Your hospice General Inpatient claims may soon be under fire, if they're not already. Everyone from the OIG to the FBI to Medicare contractors has their sites trained on this higher-paying hospice service (see Eli's HCW, Vol. XXI, No. 22).

Heed this expert advice to hold onto the GIP reimbursement you've rightfully earned:

1. Paint the whole picture. Documentation for your GIP claims needs to show exactly why patients qualify for the increased level of care. The Centers for Medicare & Medicaid Services pays about $151 for a routine home care day versus $671 for a GIP day, and CMS wants to make sure it's getting its money's worth. "Make sure the picture is being painted" for the level of hospice care received, CMS's Latesha Walker urged attendees at an industry conference last year.

Reviewers want to see exactly what symptoms the hospice is treating inpatient that are unable to be managed at home, advises Holly Swiger with Weatherbee Resources Inc. in Hyannis, Mass. "What's causing the need?" you should ask. Symp-toms necessitating GIP care can include pain, delirium, and dyspnea, notes HHH Medicare Administrat-ive Contractor CGS in its March newsletter.

And the record needs to clearly show the new interventions the hospice is taking to control those symptoms, counsels Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C. "The documentation would focus on the effectiveness of each intervention," she says.

2. Follow through with documentation. If the interventions attempted aren't working, "documentation would focus on ... what needs are still existing that have not been addressed," Adams offers.

You can show the continued need for GIP by documenting the different approaches you try to control the symptoms after the initial interventions don't work. For example, switching medications or titrating meds, Swiger says.

"When interventions are not successful, the patient may have reached an advanced stage in the terminal condition," Adams points out. "The documentation would show the continued decline ... with increased symptoms, decreasing vital signs, etc."

3. Fully document each day. Claims with longer GIP stays often see partial denials because the documentation only supports the first few days of care. You must "justify that every single day," Swiger says of furnishing GIP-level care.

Each day's documentation must show the continuing presence of symptoms warranting GIP care, the evolving care plan/interventions, and the fact that the patient isn't yet stable, experts advise.

4. Pinpoint the time of stability. Medicare covers GIP only when the patient is in "a crisis state," CGS notes in its education article. As soon as the interventions work and your patient is stable, you must bump your billing back down to the routine level of care.

You should be continually assessing the patient with involvement from the interdisciplinary team "to identify changes necessary in the plan of care," Adams tells Eli.

That means you can't keep the patient on GIP while you make a discharge plan and find a facility for the patient to transfer to. As soon as she's stable, she's done with GIP.

One option: When the patient is unable to go back home, some hospices will switch him to inpatient respite care until transfer, Adams notes.

5. Keep GIP documentation in-house. When patients reside in a SNF or other facility, you may rely on facility staff to furnish care during GIP. But smart hospices will do their own documentation, Swiger says.

Documentation from facility staff can be bare bones at best, Swiger notes. Sending your physician or nurse to review care and write her own note will help flesh out the support for your claim. Under the increased scrutiny for GIP, "the bar has been raised" for documentation, Swiger cautions.

6. Benchmark yourself. Medical reviewers and investigators will be using your own claims data to potentially single you out for scrutiny -- and worse. Know your own risk areas by comparing your billing stats to your peers, Swiger recommends.

7. Resist pressure. Some SNFs and other facilities are pressuring hospices to bill GIP levels of care for patients and, in turn, pay the facility more for those days. Don't cave in to those tactics, Swiger exhorts -- it will be your compliance record on the line and you facing a possible jail sentence if prosecutors come calling.

Bill GIP -- and pay facilities an increased rate -- only when the patient genuinely qualifies for the care level ... and your documentation can prove it, experts urge.