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Hospice Certification / Recertification Requirements

CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 9External PDF, section 20.1

To be eligible to elect hospice care under Medicare, an individual must be entitled to Medicare Part A benefits and certified as terminally ill. An individual is considered to be terminally ill if the medical prognosis is that the individual's life expectancy is 6 months or less if the illness runs its normal course.

Timeframe for Certification/Recertification

The hospice must obtain, no later than 2 calendar days (that is, by the end of the third day), and after the start of each benefit period an oral or written certification of the terminal illness. Initial certifications may be completed up to 15 days before hospice care is elected. For the subsequent periods, recertifications may be completed up to 15 days before the next benefit period begins.

If the hospice cannot obtain written certification within 2 calendar days, it must obtain oral certification within 2 calendar days. When making an oral certification, the certifying physician(s) should state that the patient is terminally ill, with a prognosis of 6 months or less. In addition, the hospice must ensure the written certification/recertification is signed and dated prior to billing Medicare, or their claim(s) may be denied.

Content of the Certification/Recertification

Section 1814(a)(7) of the Social Security Act (the Act) specifies that certification of terminal illness for hospice benefits shall be based on the clinical judgment of the hospice medical director or physician member of the interdisciplinary group (IDG) and the individual's attending physician, if he/she has one, regarding the normal course of the individual's illness. Nurse practitioners and physician assistants cannot certify or re-certify an individual as terminally ill. In the event that a beneficiary's attending physician is a nurse practitioner or a physician assistant, the hospice medical director or the physician member of the hospice IDG certifies the individual as terminally ill. In addition to the initial certification for hospice, the patient must be recertified for each subsequent hospice benefit period.

The written certification/recertification must include:

  • The statement that the individual's medical prognosis is that their life expectancy is 6 months or less if the terminal illness runs its normal course
  • The physician's brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms
    • If the narrative is part of the certification or recertification form, then the narrative must be located immediately above the physician's signature.
    • If the narrative exists as an addendum to the certification or recertification form, in addition to the physician's signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum.
    • The narrative must reflect the patient's individual clinical circumstances and cannot contain check boxes or standard language used for all patients. The physician must synthesize the patient's comprehensive medical information in order to compose this brief clinical justification narrative.
    • The narrative shall include a statement directly above the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient's medical record or, if applicable, his or her examination of the patient. The physician may dictate the narrative.
  • The signature(s) of the physician(s), the date signed, and the benefit period dates that the certification or recertification covers (for more on signature requirements, see the CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 3PDF, section 3.3.2.4).
  • For recertifications on or after January 1, 2011, the narrative associated with the third benefit period recertification and every subsequent recertification must include an explanation of why the clinical findings of the face-to-face encounter support a life expectancy of 6 months or less. Documentation must include the date of the encounter, an attestation by the physician or nurse practitioner that he/she had an encounter with the beneficiary. If the encounter was done by a nurse practitioner, he/she must attest that clinical findings were provided to the certifying physician.

Signature Requirements for Certification

Acceptable signatures

  • Handwritten signatures
  • Electronic signatures
  • Facsimile of original written or electronic signatures

NOTE: All signatures must be dated. Handwritten signatures must be hand dated.

Unacceptable signatures

  • Stamped signatures

Signatures for Initial Certifications

For the first benefit period after election of the Medicare hospice benefit, the certification must be signed and dated by the:

  • Medical director of the hospice or the physician member of the hospice interdisciplinary group (IDG); and
  • The beneficiary's attending physician (if they have one).

Note: To sign the certification, the attending physician must be a Doctor of Medicine or osteopathy and be identified by the beneficiary at the time he/she elects to receive hospice care as having the most significant role in the determination and delivery of the individual's medical care.

Signatures for Recertifications

For the recertification (and subsequent hospice benefit periods), only the hospice medical director or the physician member of the IDG is required to sign and date the certification. The beneficiary's attending physician is not required to sign and date the recertification.

Face-to-Face Encounter

For recertifications on or after January 1, 2011, a hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient prior to the beginning of the patient's third benefit period, and each subsequent benefit period.

Face-to-Face Timeframe

The encounter must occur no more than 30 calendar days before the third benefit period recertification and each subsequent recertification.

Timeframe exceptional circumstances

For new hospice admissions in the third or later benefit period: In cases where a hospice newly admits a patient who is in the third or later benefit period, exceptional circumstances may prevent a face-to-face encounter prior to the start of the benefit period.

An emergency weekend admission and the patient cannot be seen by the hospice physician or the nurse practitioner (NP) until the following Monday.

Unavailable CMS data systems resulting in the inability for the hospice to determine if the patient is in the 3rd benefit period.

In addition, if the patient dies within 2 days of admission, a FTF encounter is considered to be complete.

Untimely Face-to-Face Encounter

When a required face-to-face (FTF) encounter does not occur timely, the beneficiary is no longer certified as terminally ill, and therefore, is not eligible for the Medicare hospice benefit. In these cases, the hospice must discharge the beneficiary from the Medicare hospice benefit because he/she is no longer considered terminally ill for Medicare purposes. When a discharge occurs due to failure to perform a required FTF encounter timely, the claim should include appropriate billing information. For additional information about how to bill correctly, refer to the CGS "Untimely Face-To-Face Encounter" Web page.

Who Performs and Signs the FTF Encounter

The FTF encounter must be performed by a hospice physician or a hospice NP. The hospice physician must be employed by the hospice, a volunteer, or working under contract. The hospice NP must be employed by the hospice (receives a W-2 form from the hospice or volunteers for the hospice). Physician Assistants (PAs), clinical nurse specialists, and outside attending physicians are not authorized by section 1814(a)(7)(D)(i) of the Act to perform the face-to-face encounter for recertification.

FTF Requirements

The hospice physician or NP must attest in writing that he or she had a FTF encounter with the patient, including the date of the encounter. The attestation, which must be a separate and distinct part of the recertification, or as an addendum to the recertification associated with the 3rd benefit period, must meet the following criteria:

  • Clearly titled
  • Accompanying signature, and date signed by the individual who performed the visit
  • Date of the visit
  • Clinical findings to determine continued hospice eligibility
  • When the hospice NP/non-certifying physician performs the FTF, the attestation must also state that the clinical findings were provided to the certifying physician.

Billing Responsibilities

Before submitting claims to CGS, hospice agencies should ensure:

  • All FTF requirements are met; and
  • The written certification, including the narrative and FTF, is signed prior to billing the claim.

Additional Resources

Common Hospice Certification Errors

Medicare cannot make appropriate payment without correct dates, signatures and identifying roles of the physician(s). The following list identifies the common types of missing and inadequate information:

  • Predating physician(s) certification signatures.
  • Not having both the hospice medical director and attending physician (if applicable) sign the initial certification as required.
  • The physician's narrative is missing.
  • The physician's narrative does not include a statement attesting that it was composed by the physician.
  • The attestation statement is missing.
  • Not having verbal certifications by both the medical director and attending physician (if applicable).
  • No physician(s) signatures.
  • Illegible physician signatures.
  • Physician did not date his/her signature.
  • Not clearly stating the dates the certification period encompasses.

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