Regulations
What are the 4 levels of care provided in the Hospice benefit?
Routine, General in-patient, Continuous Care (Crisis Care), Respite
When is CC appropriate?
Continuous home care is to be provided only during periods of crisis to maintain the beneficiary at home.
A period of crisis is defined as a time in which the beneficiary requires predominately nursing care in order to achieve palliation or management of acute medical symptoms.
When should discharge planning be started and how often should it be reviewed?
On Admission and DAILY
How do you update a level of care?
Change in Care info
Name the 2 main reasons why GIP payment would be reduced to Routine care level payment?
1. the documentation did not support medical necessity.
2. the documentation submitted did not support the inpatient stay as being related to the terminal condition.
Name 4 patient care settings when CC can NOT be provided
Skilled nursing facility
Inpatient hospital, inpatient hospice facility,
Long term care hospital where skilled care is provided
Inpatient psychiatric facility
Scenario: If within a 24 hour period, 6 hours of care is provided by a hospice aide, and 4 hours of care is provided by a skilled nurse, can your agency bill for CC?
Do not count the hours as continuous care since at least 50 percent of the total care provided was not provided by a nurse. This would be billed as routine.
Is there a limit to GIP days?
There is no limit to the number of days for GIP as long as it is reasonable and necessary- However, a lengthy stay (>5 days) may trigger a review by your MAC as GIP is intended to be short term.
In addition to a daily physician order, what must be included in the POC for GIP level of care?
GIP care plan including the symptom(s) causing need for GIP.
Specific interventions to be used to manage the patient's needs.
Copies of facility notes
Medications and treatment orders
Frequency of disciplines
Name the 3 areas to focus on to avoid long lengths of stay for GIP
Evaluation
Discharge Planning
Documentation: precipitating event, include any in-home interventions that were unsuccessful
What are the 2 main criteria that must be met by a provider to provide GIP for a hospice provider?
- Medicare certified
- RN available 24/7 to provided direct patient care
Where can CC be provided?
A private residence
An Assisted Living Facility
A long term care facility where the patient is not receiving a skilled level of car
What is the purpose of GIP
GIP is for pain control or symptom management which cannot e delivered in other settings
What is the main difference between Continuous care and GIP ?
Continuous Home Care and General Impatient Care both involve treating beneficiaries with increased medical needs
Continuous Home Care manages the crisis while allowing the patient to remain at home. Generally inpatient care is managing the crisis for those who have symptoms that cannot be managed in the home.
Identify this type of Fraud:
After moving an existing patient into a hospice facility and changing the level of care for that patient, a hospice still bills Medicare, Medicaid or a private insurance company for a more costly level of care, such as Continuous Care.
Billing Fraud
Medicare covers 2 levels of inpatient care. What are they and how do they differ?
1.respite care for relief of the patient’s caregivers
2. general inpatient care which is for pain control and symptom management.
How often are you supposed to document on a patient receiving CC?
Although CHC is billed in 15-minute increments, the supportive documentation is not required to be every 15 minutes. Supportive documentation should be as frequent as necessary to support continued CHC, and is suggested at least hourly.
Who decides whether a patient needs GIP?
The hospice medical director or physician member of the hospice interdisciplinary group (“IDG”), in collaboration with the IDG, must make a determination based on the patient’s clinical condition whether the patient requires GIP care.
In addition to encounter charting, physician orders, where else should the team be documenting change in level of care, change in POC, precipitating factors and effectiveness of interventions?
IDG
CMS is monitoring CHC through targeted items on the hospice PEPPER report. Name those 2 targets
1. Continuous Home Care in Assisted Living Facility
2. (ALF) Episodes with No General Inpatient Care (GIP) or Continuous Home Care.
DAILY DOUBLE
There is an increase in fraud investigations related to continuous home care. In 1999, the Office of the Inspector General identified “billing for a higher level of service than necessary” (for example, continuous home care or the general inpatient level of care) as an area where hospices might be vulnerable to fraud and abuse. Investigators are primarily concerned with providers who do what?
Routinely offer continuous home care days to all patients and prospective patients residing in a facility when contracting with the facility. This is perceived as a violation of the Anti-Kickback Statute and as an inducement for referrals.
Do not provide continuous home care to eligible patients. Medicare certified hospice providers are required to provide all levels of care, including CHC.
Provide a significant amount of continuous home care to ineligible patients, particularly in nursing facilities.
TOH specific:
What are the 2 policies included in our CC packet?
1. Medication disposal
2. Disposal of controlled substances
DAILY DOUBLE
What are the average GIP stays in a Hospital setting and in a Skilled nursing facility setting ?
GIP stays by facility type:
Inpatient hospital stays average 9.7 days
Skilled nursing facilities stays average 23.2 days
FYI: IPU average 15.2 days
Best practice documentation/assessment:
After how many days on CC should we send a physician or a nurse practitioner to assess the patient?
3 days
Describe the 5 GIP Documentation requirements to achieve proper and complete documentation.
1. describe the services provided
2. document care that the patient caregivers cannot manage at home. Some examples are frequent changes in the dose or schedule of medications or the need for IV medications.
3. identify the precipitating event that led to GIP status.
4. Describe failed attempts to control symptoms that occurred prior to GIP admission
5. Identify specific symptoms that are actively being addressed