Hospice Levels of Care: General Inpatient Care

There are four levels of care in the Medicare hospice benefit. Hospices are paid a per diem rate based on the number of days and level of care provided during the election period. The four levels of care are routine home care, continuous home care, inpatient respite care, and general inpatient care. This job aid will focus on the general inpatient care, or GIP, level of care.

General Inpatient Care

Medicare covers two levels of inpatient care: respite care for relief of the patient’s caregivers, and general inpatient care which is for pain control and symptom management.

General inpatient care may be required for procedures necessary for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings. The focus of general inpatient care is to provide an intensity of service in response to a crisis situation that cannot feasibly be provided in any other setting. A GIP level of service typically requires frequent monitoring of a patient, and/or medication or interventions by a physician or nurse.

If the hospice and the caregiver, working together, are no longer able to provide the necessary skilled nursing care in the individual’s home, and if the individual’s pain and symptom management can no longer be provided at home, then the individual may be eligible for a short term general inpatient level of care. To receive payment for general inpatient care under the Medicare hospice benefit, patients must require an intensity of care directed towards pain control and symptom management that cannot be managed in any other setting. It is the level of care provided to meet the individual’s needs and not the location of where the individual resides, or caregiver breakdown, that determine payment rates for Medicare services.

Payment at the inpatient rate is made when general inpatient care is provided at a Medicare certified hospice facility, hospital, or SNF.

General Inpatient Care and Caregiver Breakdown

Caregiver breakdown is the loss of the individual’s support structure and should not be confused with the coverage requirements for medically reasonable and necessary care for pain and symptom management that cannot be managed in any other setting. Therefore, caregiver breakdown should not be billed as general inpatient care unless the coverage requirements for this level of care are met.

General Inpatient Care at the End of a Hospital Stay

General inpatient care under the hospice benefit is not equivalent to a hospital level of care under the Medicare hospital benefit. For example, a brief period of general inpatient care may be needed in some cases when a patient elects the hospice benefit at the end of a covered hospital stay. If a patient in this circumstance continues to need pain control or symptom management, which cannot feasibly be provided in other settings while the patient prepares to receive hospice home care, general inpatient care is appropriate.

General Inpatient Care and the Three-Day Qualifying Stay Requirement for Skilled Nursing Facilities

If a hospice patient receives general inpatient care in an acute-care hospital for three days or more, and elects to revoke hospice, then the three-day stay (although not equivalent to a hospital level of care) would still qualify the beneficiary for covered SNF services. Note that general inpatient care in a hospice facility will not qualify the beneficiary for covered SNF services.

Billing

The GIP level of care is reported with revenue code 0656. The units reflect the number of consecutive days of GIP care furnished to the patient during the billing cycle. For the day of discharge from an inpatient unit, the routine home care rate is to be paid unless the patient goes directly to another level of care or dies as an inpatient. When the patient is discharged deceased, the inpatient is to be paid for the discharge date. When billing the GIP level of care, an HCPCS site of service location code is required to reflect the location where the services were provided. Additional information on the HCPCS site of service location codes can be found in our Hospice Site of Service Codes Job Aid available on our website.

Note that each time the level of care changes, you must report separate line items for the level of care. For example, if a patient begins the month receiving routine home care followed by a period of general inpatient care and then later returns to routine home care all in the same month, in addition to the one line reporting the general inpatient care days, there should be two separate line items for routine home care.

General Inpatient Care and Visit Reporting

With the implementation of CR 8358, visit reporting requirements while in the GIP level of care are based on the location where the care is provided. For GIP care provided to hospice patients in SNFs (site of service HCPCS code Q5004) or in hospitals (site of service HCPCS codes Q5005, Q5007, Q5008), you will report each visit performed by hospice-employed nurses, aides, social workers, PTs, OTs, and speech-language therapists along with their associated time per visit in the number of 15-minute increments, on a separate line. This includes certain calls by hospice social workers. For all visit/call reporting, only report visits/calls by the paid hospice staff; do not report visits by non-hospice staff.

CMS is not changing the existing GIP visit reporting requirements when the site of service is a hospice inpatient unit (site of service HCPCS code Q5006). Therefore, for GIP billing in hospice inpatient units, you will report the total number of visits performed by nurses, aides, and social workers who are employed by the hospice each week while in the GIP level of care. For each week, beginning on Sunday and ending on Saturday, you will indicate the number of services/visits provided by nurses (registered, licensed and/or nurse practitioner), aides, and social workers. The following tables provide the coding requirements. Additional information on reporting visits can be found in our Hospice Visit Reoporting Job Aid available on our website.