5CFH6: Initial Certification Not Timely

The claim has been fully or partially denied, as the documentation submitted for review did not include an initial certification signed timely by the medical director and attending physician.

Untimely Certification Example

• Situation: 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)

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

Resources

• CMS Internet-Only Manuals (IOMs),  Publication 100-02, Medicare Benefit Policy  Manual, Chapter 9, Section 20.1
• Code of Federal Regulations, 42 CFR - Sections 418.200 and 418.22