Medicare Certification and Recertification in the Hospice Setting

Updated on May 11, 2017: CMS seeks comments for possible future changes to the rule governing the source of clinical information for certifying terminal illness

For hospice service providers, the Medicare certification and recertification process is an essential step in ensuring Medicare payment for their clients. In order to maintain the Medicare hospice benefit, a patient must be certified as terminally ill; which is defined as having a medical prognosis declaring the individual’s life expectancy to be 6 months or less should the illness run its typical course.

Description of Certification and Recertification Documents

If the patient in question has an attending physician for their care, then the initial certification should be based on the clinical judgment of that physician, in addition to the hospice medical director or physician member of the interdisciplinary group (IDG). If a patient’s hospice benefit period has expired and they are still in need of Medicare, that patient will need to be “recertified” in addition to the initial certification.

What must these documents include? In addition to a statement that the patient’s medical prognosis is a “life expectancy of 6 months or less should the illness run its normal course”, the certifying physician must provide:

  • A brief narrative explaining all clinical findings that support the patient’s life expectancy.
  • The physician’s signature immediately following said narrative.
  • A statement included with the narrative, including the physician signature and date, which ensures that by signing the form, the physician is in fact confirming that they composed the narrative based on their personal review of the patient’s medical record or their examination of the patient.
  • Benefit start and end dates.
  • Documentation explaining why clinical findings of a face-to-face encounter support a life expectancy of six months or less. If this encounter was conducted by a nurse practitioner, they must attest that the clinical findings were provided to the certifying physician.
  • Recertification of all subsequent hospice benefit periods require the hospice Medical Director or physician member to sign and date the certification.

In the fiscal year 2018 proposed rule, CMS-1675-P, CMS has raised a question about the sourcing of the clinical information used to support a medical prognosis of terminal. “This raises the question as to what clinical information the hospice medical director (or hospice physician designee) is relying on to support his or her certification that the individual is terminally ill and from where this information was obtained,” CMS says in its proposed rule posted in the Federal Register May 3, 2017.

CMS notes there are multiple clinical tools and guidelines, specifically the Medicare Administrative Contractor Local Coverage Determinations (LCD), that assist patient-designated physicians and hospice medical directors or hospice physician designees in determining a “terminal” prognosis. Most of the conditions in the LCD are long-term and would likely be documented in a patient’s historical files with a longtime physician. That doctor typically becomes an attending physician once a patient elects hospice. In accordance with CMS regulation §418.22(c)(1)(ii), “only the initial certification has to involve the attending physician and only IF the patient has designated one.” Without a designated attending physician, the responsibility for certifying a patient as “terminal” would rest solely on the hospice medical director or physician member of the hospice interdisciplinary group. Additionally, the regulation doesn’t require either of these hospice certifiers to have a face-to-face encounter with the patient when initially making the call that the patient is terminally ill.

Since Medicare’s hospice benefit doesn’t cover visits to the patient until he has been certified as terminally ill, an election statement has been signed, and a plan of care has been established, “information regarding the patient’s health status from hospice staff should not be the sole documentation used to support the initial certification requirement,” the new rule states.

The U.S. Department of Health and Human Services’ Office of the Inspector General has identified weaknesses in the area of hospice eligibility, including instances of insufficient hospice documentation and inappropriately reported diagnoses. “There are ongoing concerns that some hospice patients may be inappropriately certified as terminally ill,” the proposed CMS rule states.

As a result, CMS is “soliciting comments for possible future rulemaking on amending the regulations at §418.25 to specify that the referring physician’s and/or the acute/post-acute care facility’s medical record would serve as the basis for initial hospice eligibility determinations.” Such a change aligns with current benefit eligibility criteria. CMS is also seeking comments on amending text at §418.25 “to specify that documentation of an in-person visit from the hospice medical director or the hospice physician member of the interdisciplinary group could be used as documentation to support initial hospice eligibility determinations, only if needed to augment the clinical information from the referring physician/facility’s medical records.”

Comments must be received no later than 5 p.m. on June 26, 2017.

Are There Time Restrictions on Certification? Medicare Certification and Recertification in the Hospice Setting

According to CGS, a Celerian Group Company, a hospice must obtain either verbal or written certification of a patient’s terminal illness no later than 2 calendar days after the start of each benefit period whether it be the initial certification or subsequent certifications. Initial certifications may be completed up to 15 days before hospice care is elected for the patient. Subsequent certifications may be completed up to 15 days before the start of the next benefit period.

What are Common Hospice Certification Errors?

It’s imperative that all documentation contains the correct dates, signatures and identifying roles of the physicians. Without this correct information, Medicare can’t make suitable payment.

What are the common errors or omissions involving these documents?

  • Not having the signatures of both the hospice medical director as well as the attending physician.
  • Missing physician narrative.
  • Physician narrative with no supporting statement.
  • No verbal certifications from the medical director and attending physician (if applicable).
  • Lack of or illegible physician signatures.
  • No date next to physician’s signature.
  • Unclear statement of dates that the certification period covers.

For more detailed information describing the certification and recertification process, providing specialized attention to the face-to-face encounter requirement, the National Hospice and Palliative Care Organization (NHPCO) offers a pocket guide available for purchase on their website.

At Manchester Specialty Programs, we offer a hospice insurance program that offers an all-lines solution with tailored coverage specific to the hospice community, from select top-tier insurance companies. Regulatory Audit Insurance Coverage for government audits (RACs/ZPICs) is also offered as part of our management liability program, and is especially important for firms that do Medicare billing.  For more information about our comprehensive products and services, please contact us today at 855.972.9399.

Sources: CMS, HHS