Hospice Certification of Terminal Illness
For a patient to be eligible for the Medicare hospice benefit, the beneficiary must be certified as being terminally ill. A beneficiary is considered to be terminally ill if the medical prognosis determines the individual's life expectancy is six months or less if the illness runs its normal course. The certification/recertification is critical to ensure Medicare payment for the hospice services you provide.
Timeframe for Certification/Recertification
The hospice must obtain oral or written certification of terminal illness, no later than two calendar days (by the end of the third day) after the start of each benefit period (initial and subsequent).
Initial certifications may be completed up to 15 days before hospice care is elected.
Recertifications may be completed up to 15 days before the start of the next benefit period.
If written certification/recertification cannot be obtained within two calendar days, an oral certification must be obtained. The hospice must determine who may accept an oral certification from a physician in compliance with state and local regulations.
Content of the Certification/Recertification
The certification should be based on the clinical judgment of the hospice medical director (or physician member of the interdisciplinary group (IDG), and the patient's attending physician, if he or she has one. Nurse practitioners and physician assistants cannot certify or recertify an individual as terminally ill. If the patient’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 benefit period, the beneficiary must be recertified for each subsequent hospice benefit period.
The written certification/recertification must include:
- The statement that the beneficiary's medical prognosis is that the life expectancy is six months or less if the terminal illness runs its normal course
- A brief narrative, written by the certifying physician, explaining the clinical findings that support the beneficiary's life expectancy of six months or less. This narrative can be a part of the certification/recertification form or as an addendum to the form.
- If the narrative is part of the form, it must be located immediately above the physician's signature
- If the narrative is an addendum, the physician must also sign the addendum immediately following the narrative
- Do not include check boxes or standard language used for all patients. The narrative cannot be completed by other hospice personnel; it must be completed by the certifying physician.
- The narrative shall include a statement, located above the physician signature and date, that attests to the fact that by signing the form, the physician confirms that he or she composed the narrative based on his or her review of the patient's medical record or his or her examination of the patient
- The benefit period dates that the certification or recertification covers
- Narratives associated with the third and subsequent benefit periods must explain why the clinical findings of the face-to-face encounter support a life expectancy of six 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.
Signatures for Initial Certifications
For the initial benefit period, 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 applicable)
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 (for 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.
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 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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