Hospice Certification Errors

This article reviews the reasons a medically reviewed record may be denied for certification:

5CFH2 -No certification present
The claim has been fully or partially denied, as the documentation submitted for review did not include a certification of terminal illness to cover the dates of service billed.

5CFH4 - Initial certification not signed

5CFH5 - Subsequent certification not signed
The services billed were not covered because the documentation submitted for review did not include an initial certification that was signed by both the medical director and attending physician (initial certification) or medical director subsequent recertification)

I certify Mr. Patient to be terminally ill with a prognosis of six months or less to live if the disease follows its normal course”

Dr. Doolittle__________________________
Physician Signature                       Date
This looks like a signature block 

I certify Mr. Patient to be terminally ill with a prognosis of six months or less to live if the disease follows its normal course”

Dr. Attending
Physician Signature                       Date
Signature is missing the date

5CFH3 - No certification for dates billed
The services billed were not covered because the documentation submitted for review did not include a certification covering all of the dates billed

Dates of service billed 11/01/20XX-11/30/20XX
Initial benefit period 8/15/20XX – 11/12/20XX
Second benefit period 11/13/20XX – 02/12/20XX (This certification was not submitted)

5CFH6 - Initial certification not signed timely
The services billed were not covered because the documentation submitted for review did not include an initial certification that was signed timely by both the medical director and attending physician

Start of Care is March 1, 20XX
The attending physician signs March 1, 20XX
Hospice medical director signs March 10, 20XX (no verbal certification present)

I certify that Sally Stroke is terminally ill with a diagnosis of CVA and has six months or less to live provided the disease follow it’s normal course”
V.O. Qwen LPN Jan 14, 20XX

Henry Healer MD Jan 23, 20XX
Attending Physician
Fred Fixemup  Jan 26, 20XX
Medical Director
Does not indicate which physician gave the verbal certification

5CFH7 -Subsequent certification not timely
The services billed were not covered because the documentation submitted for review did not include an initial certification that was signed timely by both the medical director

Benefit period  4-1-20XX to 5-30-20XX
Joe Surgeon                  4/16/20XX
Medical Director
No verbal certification present, certification signed later than two days into the benefit period

Benefit period 4-1-20XX to 5-30-20XX
Verbal Certification 4-1-20XX  Qwen LPN
Joe Surgeon                  7/16/20XX
Medical Director
Claim billed to Medicare 7/2/20XX
Physician signed after claim was billed to Medicare

5CFH8 - No prognosis statement
The services billed were not covered because the physician’s certification submitted for review did not include a prognosis statement of 6 months or less as required by Medicare guidelines

I certify patient Leo Corn Wallace is terminally ill
Ray D Ology          11/12/20XX
The six months is not mentioned

How to Prevent Denials Related to Physician Certification

• In order to be eligible for hospice benefits under Medicare, the beneficiary must be certified as being terminally ill. The hospice must obtain written certification of terminal illness for each benefit period.
• The hospice must include the written certification, to cover the dates of service billed, with the medical records submitted for review when responding to an ADR. All dates billed must be covered by a certification to be payable under the Medicare hospice benefit.
• If more than one certification covers the dates of service in question, submit all the related certifications for review.
• For the first 90-day period of hospice coverage, the hospice must obtain, no later than two calendar days after hospice care is initiated, (that is, by the end of the third day), oral or written certification by the medical director or the physician member of the hospice interdisciplinary group and the beneficiary’s attending physician. If one physician is serving in both capacities, this must be clearly identified on the certification
• Written certification must be on file in the hospice beneficiary’s record prior to submission of a claim to the MAC. If these requirements are not met, the payment begins with the day of certification.
• The initial certification may be completed up to two weeks before hospice care is elected.
• If the attending physician and the medical director are the same, the certification must clearly identify this information
• Certifications for subsequent benefit periods must be obtained no later than two days after the beginning of the new benefit period. Only one physician’s signature is required on a subsequent certification.
• Verbal certification may be submitted; however, there must be documentation in the medical records to indicate the certification was obtained within the time frame indicated above.
• Verbal certification must be followed by a written certification, signed and dated by the physician prior to billing Medicare for the hospice care.
• If no verbal certification is present and the written certification is signed later than 2 days after the beginning of the benefit period, allowable days will begin with the date of the physician’s signature

For more information, refer to:

• CMS Internet-Only Manuals (IOMs),  Publication 100-02, Medicare Benefit Policy  Manual, Chapter 9, Section 20.1 (PDF, 616 KB)
• Code of Federal Regulations, 42 CFR - Sections 418.20 and 418.22