How to Evaluate the Use of General Inpatient Care

Kennedy Terminal Ulcer Excelas Medical Legal Solutions

Hospice General Inpatient Care: A Guide to Ensuring Regulatory Compliance

General inpatient care (GIP) is the second most expensive level of hospice care. GIP, which provides 24/7 nursing care, is intended for short-term use to manage pain and symptoms when palliation cannot be achieved in other settings. Symptoms that may require GIP can include unmanaged pain that is not responsive to lower levels of treatment, intractable nausea and vomiting and/or related dehydration, wounds that require frequent dressing changes or worsening wounds, respiratory distress, and delirium. Because GIP stays are designated only for advanced or difficult-to-control symptoms, it must be performed in a hospital, Medicare certified hospice unit, or skilled nursing facility (SNF).

GIP has recently been identified by the U.S. Office of the Inspector General (OIG) as an area that may be vulnerable to fraud and abuse in Medicare/Medicaid billing. A 2013 report by the OIG revealed the following disparities in GIP care at inpatient hospice units, in comparison to GIP care at hospitals and SNFs:

  • GIP stays were 50% longer in hospice inpatient units than in hospitals, and 20% longer than in SNFs;
  • 58% of all GIP provided toMedicare beneficiaries occurred in hospice inpatient units while hospitals provided 33% and SNFs provided 8%; and
  • 35% of Medicare beneficiaries at hospices with inpatient units received GIP, compared to 12% for hospices without inpatient units.

As such, GIP has become a focus area for regulatory auditors—as well asa prime subject of internal audit by healthcare providers seeking to assess how appropriately GIP is being used in their facilities. Conducting an internal GIP audit can give hospice care providers you the insight they need to be confident in their billing accuracy.

The Best-Practice Approach
One of the most effective ways to approach an internal GIP audit is to do it with the assistance of an outside contractor. A good contractor will perform an objective assessment with the purpose of determining whether GIP was appropriately utilized and whether the justification for the level of care is sufficiently documented in the medical record. Following are the most important bases to cover when conducting an internal GIP audit:

  • Assess whether necessary criteria for the initiation, continuation and discontinuation of GIP care were sufficiently documented in each individual case;
  • Evaluate whether the facility satisfactorily completed its documentation across all cases;
  • Identify any trends or patterns in documentation that indicate areas for improvement; and
  • Identify any instances in which the the documentation does not support the appropriateness of GIP admission

What to Look For

A good contractor begins the audit process upon receiving your random sample of medical records from patients for whom GIP care was billed. As such, they should be able to work with paper records as well as electronic medical records—either through a secure file-sharing network or via your EMR system.

Analysts should then review each individual record, examining all information regarding the decision to place patients in GIP. The best practice approach encompasses an unbiased and completely objective analysis of all criteria that are required to justify the use of GIP care, recording the presence or absence of necessary supporting documentation, and noting any lack of justification for the level of care. Analysts should also look for the following information:

  • Assessed need for change in level of care;
  • Signed and dated physician order to initiate GIP;
  • Updated plan of care reflecting initiation of GIP, reason for GIP and interventions;
  • Involvement of interdisciplinary group (IDG) members in decision to initiate GIP;
  • Daily RN visits or calls to assess ongoing need for GIP;
  • IDG support for continuation of GIP;
  • Involvement of IDG and attending physician indicating discontinuation of GIP; and
  • Signed and dated physician order to discontinue GIP


Upon completion of the project, the contractor should provide you with an audit report that scores the cases both individually and cumulatively. At its most basic level of measurement, the audit report provides a simple yes/no indication of the presence or absence of each type of documentation, by case. Each case also receives a score indicating the overall percentage of required criteria that were satisfactorily documented.

The report should then include cumulative measures of how well the facilities are doing with documentation. First, the report should provide an average score across all cases, which indicates how complete the documentation was overall, in regard to all of the criteria in question. Second, the report should include cumulative percentage scores per criterion, which indicate how often each type of documentation was satisfactorily completed. Finally, the report should have relevant notes if the analysts find the use of GIP to be potentially questionable in any of the records reviewed.

In short, the information received in the audit report should be considered as a benchmark to help identify areas of competence as well as trends that indicate areas for improvement. Because the issue of GIP care is a “hot topic” in the regulatory sector, providers who make a proactive decision to gauge their success, and put improvement measures into place now, are taking valuable steps in maintaining their compliance going forward.


There are many regulatory focus areas in which an internal audit would be advantageous. Some examples include:

  • Hospice eligibility;
  • CMS documentation requirements for hospice admission;
  • Hospice length of stay and conditions/diagnoses in SNF settings;
  • Appropriate use of Ultra High Therapy RUGs in SNF settings and assessment of supporting documentation; and
  • Appropriate use of atypical antipsychotic medications and assessment of supporting documentation

If you need to conduct an internal GIP audit, contact Excelas to help you navigate the process with expert advice and our team of experienced analysts.

DISCLAIMER: The preceding case study is a true story. Excelas, LLC values the integrity of our client relationships. To protect them from uninvited or unwarranted attention, contact, exposure or scrutiny, we do not disclose the names, or any other identifying information, of the corporate entities, facilities or defense firms with whom we do business.
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