Navigating GIP Requirements

1. Navigating GIP Requirements EvergreenHealth Hospice Stephanie Beebe, BSN, RN, CHPN Meredith Brass, MD Celia Harper, BSN, RN, CHPN

2. EvergreenHealth Hospice – Who we are Non-profit, hospital system based hospice out of Kirkland, WA Medicare-certified in 1990 Average outpatient daily census: 510 15 bed inpatient facility providing GIP and residential care

3. Targeted Probe and Educate Source: https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/medical-review/targeted-probe-and-educatetpe.html CMS's Targeted Probe and Educate (TPE) program is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help. The goal: to help you quickly improve. Medicare Administrative Contractors (MACs) work with you, in person, to identify errors and help you correct them.

4. TPE: Common Claim Errors Source: https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/medical-review/targeted-probe-and-educatetpe.html

5. TPE Cycle Source: https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/medical-review/targeted-probe-and-educatetpe.html

6. TPE for EvergreenHealth Hospice • Probe: GIP stays ≥ 7 days • Review conditions of payment, including: • Beneficiary election statement • Certification of Terminal Illness • Review documentation if GIP was reasonable and necessary each day billed • Physician progress notes • Nursing progress notes • Orders • MAR

7. TPE Round 1 Results • 40 claims reviewed • 13 paid in full (GIP was reasonable and necessary) • 8 paid GIP for some dates, and Routine for all others • 13 paid Routine rate • 6 Denied Payment Error Rate ≈ 47% (goal is ≤15%to be released from TPE cycle)

8. TPE Round 1 Impact • Needed to improve, and quickly • 45 days from education until beginning of next round of TPE • What did we learn, and more importantly, what did we do?

9. What is GIP?

10. General Understanding of GIP: an auditor's perspective - NGS 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. https://www.ngsmedicare.com

11. NGS – Hospice GIP Check Off List https://www.ngsmedicare.com/ngs/wcm/connect/ngsmedicare/d8c0caf3-6195-4f65-a839-6718d1a32d31/1839_0816_GIP+Check+Off+List_508.pdf?MOD=AJPERES&CVID=lpXacHI

12. Improving Documentation in Practice Goal: Support GIP status in appropriate patients Better documentation of symptom burden requiring GIP stay Clearly documenting active interventions provided Requires: Multi-level approach to improved documentation across disciplines Step 1. Provider note changes Step 2. Nursing shift & IDT clinical documentation changes Step 3. Administrative improvements

13. Understanding our Facility • EvergreenHealth’s inpatient center is overseen by two primary providers • GIP patients receive a daily provider visit and note • Nurses work 12 hour shifts • Each RN completes nursing shift summary with significant events detailed, including symptoms and interventions • Daily case management team/provider “huddle” • discussing that day’s plans, GIP status, discharge planning

14. Provider Notes Why focus on Provider notes first? Fewer individuals affected allowing easy/immediate change Provides real-time and ongoing education to staff regarding GIP indications Provides groundwork for enhancement and clarification of nursing documentation

15. Comprehensive Goal Add supportive details to describe extent of symptom burden Be specific in interventions required to gain symptom control Be detailed in adjustments to medications Document clearly when requiring IV medication and WHY the patient requires IV medication Avoid passive/self-rewarding language such as “comfortable”

16. Comprehensive, Aren’t They? Ideal Note S: Patient seen this am and rouses to deny pain, unable to report night events. Per nursing staff, overnight he had recurrent episodes of restlessness and agitation, repeatedly pulling at clothing and resisting cares, with multiple attempts out of bed and required 2 prn doses of IV Haldol as well as 2 prn doses of IV lorazepam due to severity of agitation. <EXAM> A/P: 89 yo male with dementia admitted with uncontrolled agitation Delirium -Increase Haldol to 1 mg TID routine with PRN available -Continued oral and IV back up required as patient with rapid escalation of symptoms requiring rapid relief and intermittent refusal of oral medications -Consider transition to quetiapine if insufficient control of agitation -Continue po/IV PRN lorazepam available if unresponsive to Haldol -Continue to monitor for reversible causes including urinary retention, constipation, pain Rapid Note S: Restlessness overnight requiring additional doses of lorazepam and Haldol. Patient denies pain and appears comfortable at time of visit. <EXAM> A/P:89 yo male with dementia Delirium -Increase Haldol dose to 1 mg TID -Prn lorazepam available -Ensure pain controlled

17. Specifying Indication for GIP Important to document indication for GIP Make sure to be specific with indication/criteria to support continued GIP level of care Provides auditors understanding of provider decision to continue GIP level of care

18. Examples of Indications for GIP: Uncontrolled symptomfailed to respond to… Uncontrolled symptomcontinuing to require… Requiring complex IV medication administration for… Continues to require ongoing 24 hour skilled nursing assessments to monitor…

19. Indications are Personalizedto Each Patient Daily! • Avoids inaccurate statements/generalizations • Provides clarity to staff regarding current role of GIP in patient hospice journey • Forces focuseddaily assessment: • Symptoms being targeted • Current level of symptom management • Current route of medications • Expected time until able to discharge for planning needs

20. Example in Action! Indication for GIP: Continues to require complex IV medication to control nausea/vomiting including IV haloperidol, dexamethasone, ondansetron and lorazepam. Unable to transition to oral/rectal due to bowel obstruction preventing oral absorption and perineal tumor/pain preventing rectal administration. Unable to provide current medications in a lower level of care setting.

21. Nursing Documentation Provider leads the documentation and helps establishes the plan of care • “Indication for GIP. Patient with ongoing pain requiring continued skilled nursing assessment to monitor response to interventions and ongoing active titration of medications as described in plan of care including monitoring ability of PCA use” • Cue to nursing: • Assess and document to pain using descriptive charting. Include comments related to titration of medication and ability to use PCA. • Ensures all staff up to date with the IDT plan of care

22. Nursing Documentation • Nursing staff tend to document to the positive • Patient comfortable with 10 doses of PRN medication • Subtext: “I did a good job, I helped this patient”. Even “this is a good patient who responds to my interventions”. • Instead need to document to reality, but from a different perspective • Patient still has significant need for PRN medication to control pain requiring 10 doses of PRN medication

23. Nursing Documentation Must Answer Certain Questions Answer daily: “Why GIP?” What are the patient’s symptoms today? (be specific!) What interventions have been implemented (be specific!) How has the patient responded? What is the ongoing plan?

24. Paint the Picture with Words

25. Don’t Leave Documentation Open to Interpretation Use of “as evidenced by” for supportive documentation. It’s not used often enough! Shortness of breath as evidenced byuse of accessory muscles on inspiration, pursed-lip breathing, and use of break through medication for symptom control.

26. Don’t Leave Documentation Open to Interpretation Be factual • Only information you see, hear, or otherwise collect through your senses • Describe, don’t label • Describe behavior, not conclusions such as “confused,” “drunk,” or “violent” • State facts, not value judgments such as “No change” or “Ate well” • Be specific • Use neutral language • Avoid bias and be objective • Document what was said in quotation marks

27. Descriptive Documentation

28. IDT Clinical Documentation • MSWs focus on working on discharge planningDischarge planning starts at admission • Admission agreement with discharge plan written and signed • CNA & Chaplain documentation • Adds weight to complexity of the care

29. Administrative Interventions • Organize documentation • Use your MAC’s website as a guide • NGS GIP Check-off List • Underline supporting documentation • Appeal if you disagree with the determinations • Include your medical director for decisions • Include a cover letter outlining daily GIP need • Pre-claim review of GIP documentation

30. Underlining Supportive Documentation Payment Error Rate ≈ 47% (goal is ≤15% to be released from TPE cycle) Started underlining supportive GIP documentation

31. Use the Appeals Process • Included the hospice medical director with the appeals process • Appealed 24 determinations: • 21 were found favorable (paid in full) • 1 found partially favorable • 1 denied

32. Round 2: How are We Doing? Expected to receive 40 requests Under the 15% Payment Error Rate

33. Questions?