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Medicare Hospice Certification andRecertification Compliance Guide§ 418.22 Certification of Terminal IllnessRevised November 2021NHPCO.ORG
§ 418.22 CERTIFICATION OF TERMINAL ILLNESSThis document provides guidance about thecomponents that are required for Medicarehospice certification of terminal illness.Each component that is required on thecertification and recertification form is outlinedwith suggested text (in red) for a provider’scertification/recertification form.DISCLAIMERThis compliance guide has been gathered and interpreted by NHPCO fromvarious resources and is provided for informational purposes only. It shouldnot be viewed as official guidance from CMS or Medicare AdministrativeContractors (MACs). It is always the provider’s responsibility to determineand comply with applicable CMS, MAC, and other payer requirements.Further, this guide does not constitute legal advice and is not intended totake the place of legal advice.CONTENTSCOMPLIANCE FORHOSPICE PROVIDERSRevised November 2021A. Components at a glanceNational Hospiceand PalliativeCare OrganizationC. Certificationsa. Components and What They Need to Containb. When/Timeframesc. WhoB.OverviewD. Narrative and Attestationa. Components and What They Need to Containb. When/Timeframesc. WhoE.Face-to-Face Encounter (Visit) and Attestationa. Components and What They Need to Containb. When/Timeframesc. WhoF.SignaturesG. Late Face-to-Face EncountersH. TransfersI.ReferencesMedicare Hospice Certification and Recertification Compliance GuideNHPCO.ORG 01
§ 418.22 CERTIFICATION OF TERMINAL ILLNESSA. COMPONENTS AT A GLANCECOMPONENTWHATWHEN/TIME FRAMESWHOCertificationStatement1. Statement of lifeexpectancy of 6 months orless should the terminalillness run its normalcourse2. If cannot obtain writtenwithin 2 days afterelection/start of benefitperiod, hospice mustobtain a verbal (oral)certification with in 2 days.1. H ospice physician3. Can obtain up to 15 daysbefore election/start ofbenefit period.2. A ttending (1st periodonly) if they have one3. If attending chosen is aNP or PA, no attendingcertification is allowed4. W ritten certificationstatement before thehospice can billNarrative1. Brief explanation ofclinical findings thatsupports a life expectancyof 6 months or less1. A fter the F2F (for 60 dayperiods).2. Must have before hospicecan bill.1. H ospice physician whoalso certifies (certifyingphysician)2. Uses findings of F2F (for60 day periods)3. A ttestation that thephysician composed thenarrative. Located abovethe signature and date line.Face-to-Face(F2F) Visit forany 60 daybenefit period(3rd and on)1. V isit (encounter) made togather clinical findings todetermine continuedeligibility.2. A ttestation that visit wascompleted and date itwas completed.3. Signature underattestation.Medicare Hospice Certification and Recertification Compliance Guide1. N o more than 30 daysbefore the benefit periodstarts.2. Can occur on same day asnew benefit period.3. A ttestation and signaturebefore billing.1. H ospice employed NP orhospice employed orhospice contractedphysician.2. A ttestation by hospiceemployed NP or hospiceemployed or hospicecontracted physician whomade the visit.NHPCO.ORG 02
§ 418.22 CERTIFICATION OF TERMINAL ILLNESSB. OVERVIEWIn order to be eligible to elect hospice care under Medicare, an individualmust be entitled to Part A of Medicare and certified as being terminally ill.Initial certification must be made by the medical director/hospice physicianand the patient’s attending physician, if the patient has one. Nursepractitioners and physician assistants are not permitted to provide initialcertification or recertification. The medical director/hospice physician inconjunction with the Interdisciplinary Group must determine recertification(any period other than the first 90 days) for continued hospice care. Ahospice face-to-face encounter must occur prior to recertification for any60 day period.Hospice Medicare Benefit Periods 1 st benefit period is 90 days 2 nd Benefit period is 90 days U nlimited 60 day benefit periodsThe periods are only available in theorder listed above.All components of the certification (certification, narrative and hospiceface-to-face encounter for those in the 3rd and subsequent benefit periods)must be completed according to the regulatory requirements to have acomplete and completed certification or recertification.Brief PhysicianNarrativeCertificationCERTIFICATIONOF TERMINALILLNESS§ 418.22Medicare Hospice Certification and Recertification Compliance GuideFace-to-FaceEncounter(3rd benefit period)NHPCO.ORG 03
§ 418.22 CERTIFICATION OF TERMINAL ILLNESSC. CERTIFICATIONComponents and What it Needs to Contain1. Must specify that in the physician’s clinicaljudgment, the patient’s prognosis is for a lifeexpectancy of 6 months or less if the terminalillness runs its normal course.2. Certification is made based on clinical informationand other documentation supporting eligibilitycontained within the medical record. The physicianconsiders the following when making thisdetermination:a. The primary terminal condition;b. Related diagnosis(es) if any;c. Current subjective and objective medical findings;d. Current medication and treatment orders;e. Information about the medical management ofany of the patient’s conditions unrelated to theterminal illness.3. Must contain the benefit period dates that thecertification or recertification covers.When/Timeframes1. Obtain the verbal (oral) certifications no morethan 15 days before or 2 days after admission. Thisallows billing for all days once written certificationsare obtained.2. Hospice staff must make an appropriate entry inthe patient’s medical record as soon as they receivea verbal (oral) certification. It is not necessary forthe physician to sign the verbal (oral) certification.3. If the verbal (oral) or written certifications are notobtained within the above specified time frames,the billable date is the date that the writtencertifications are obtained.b. Benefit period start date 9/15. Verbal (oral)obtained no earlier than 8/31 and no later than9/17. Written certification before billing.c. Benefit period start date 9/15. No verbal (oral)obtained. Written obtained 9/18. Billable datesstart 9/18.5. Note-a verbal (oral) certification is not aphysician’s order and may be taken by staff otherthan nurses if permitted by hospice policy andstate regulations, if any.Who1. Hospice physician all periods (referred to as thecertifying physician).2. Attending physician (1st period only) if they haveone as identified on the hospice election statement.Attending physician means a physician, nursepractitioner or physician assistant, who is identifiedby the patient at the time they elect their hospicebenefit as having the most significant role in thedetermination and delivery of the patient’s medicalcare. If identified attending physician is NP or PA,then there is no attending certification.3. CMS clarified in March 2021: “If there is no attendingphysician designated, the original certification (first90 day period) does not require the hospice medicaldirector to sign in two places. The hospice physiciancould sign in both places if they are the designated‘attending physician.’ Currently, policy does not statethat the hospice physician is required to sign thecertification/recertification as both the hospicedirector and attending physician.” NHPCONewsbriefs March 25, 20214. Written certification must be obtained priorto billing.Example:a. Benefit period start date 9/15. Verbal (oral) orwritten certification obtained no earlier than8/31 and no later than 9/17.Medicare Hospice Certification and Recertification Compliance GuideNHPCO.ORG 04
§ 418.22 CERTIFICATION OF TERMINAL ILLNESSD. NARRATIVE AND ATTESTATIONComponents and What They Need to ContainWho1. Brief explanation of clinical findings that supportthe 6 month or less prognosis and attestation whocomposed the narrative.1. The narrative statement must be composed by thecertifying physician. This is the same physician whosigns the certification statement.2. The narrative statement can be part of thecertification of terminal illness form, or it can bean addendum to the certification form. Thenarrative and attestation must be locatedimmediately prior to the physician’s signature. Ifthe narrative statement is an addendum, indicatethat it is an addendum on the certification ofterminal illness form.2. NHPCO recommends that the hospice medicaldirector/hospice physician compose the narrativestatement versus the attending physician for thefirst 90-day certification period. The hospice medicaldirector/hospice physician is more knowledgeableabout the wording requirements in the narrativestatement. Since only the hospice medical director/hospice physician provides certification for the 2nd90 day and all 60 day periods, this means only thehospice medical director/hospice physician willcompose the narrative.3. An attestation statement located directly abovethe physician signature must be included with thephysician narrative statement. NHPCO suggestedtext follows:Physician narrative attestation: I confirm that Icomposed this narrative statement and that it isbased on my review of the patient’s medical recordand/or examination of the patient.4. The certifying physician’s printed name, signature,and date should appear below the attestationstatement.5. If the physician forgets to date the certification, anotarized statement or some other acceptabledocumentation can be obtained to verify when thecertification was obtained.When/Timeframes1.After the Face-to-Face.2.Before billing.Medicare Hospice Certification and Recertification Compliance GuideNHPCO.ORG 05
§ 418.22 CERTIFICATION OF TERMINAL ILLNESSE. F ACE-TO-FACE ENCOUNTER (VISIT)AND ATTESTATIONComponents and What They Need to ContainWhen/TimeframesFace-to-face (F2F) encounter and attestation (for 3rdand all subsequent benefit periods).1. No more than 30 days before 3rd and allsubsequent benefit periods (any 60 day benefitperiod) starts and can occur on same day as newperiod starts.1. F2F encounter is to gather clinical findings todetermine continued eligibility. It is not todetermine eligibility.2. The face-to-face encounter attestation statementis completed by the physician or nurse practitioner(NP) that completed the face-to-face encountervisit and must include the date of the visit(encounter).3. The face-to-face encounter attestation statementcan be part of the certification of terminal illnessform or it can be an addendum to the certificationform. If the face-to-face encounter attestationstatement is an addendum that should be indicatedon the certification of terminal illness form.4. When a nurse practitioner or hospice physicianwho is not the certifying physician, completes theface to face encounter, the attestation must statethat the clinical findings of that visit were providedto the certifying physician for use in determiningwhether the patient continues to have a lifeexpectancy of 6 months or less, should the illnessrun its normal course.5. Suggested face-to-face encounter attestation text:2. Prior to written certification and narrative.3. If a patient is admitted in the 3rd or subsequentbenefit period, the face-to-face encounter mustoccur prior to admission unless an exceptionalcircumstance exists.4. If exceptional circumstances prevent a face-toface encounter to occur prior an admission of apatient in a third or later benefit period:a. Complete the face-to-face encounter within 2calendar days after admissionb. Document the exceptional circumstances.c. Billing may occur from the date of admission.d. For such documented exceptional cases, if thepatient dies within 2 days of admission withouta face-to-face encounter, the face-to-faceencounter is deemed as complete.Who1. Hospice employed NP2. Hospice employed or hospice contracted physician.I confirm that I had a face-to-face encounter with(Beneficiary’s Name) on ( date) and that ifI am not the certifying physician. The clinicalfindings were provided to the certifying physicianfor use in determining continued eligibility forhospice care.Medicare Hospice Certification and Recertification Compliance GuideNHPCO.ORG 06
§ 418.22 CERTIFICATION OF TERMINAL ILLNESSF. SIGNATURESH. TRANSFERS1. Physicians must sign and date the components ofthe certification themselves (stamped physiciansignatures are not acceptable).1. When a patient transfers from another hospice(Make note: can only occur once in a benefit period)2. The signatures must include “legible identifier” inthe form of a handwritten or electronic signature.3. Signature logs may be used that lists the typed orprinted name of the author associated with initialsor an illegible signature.G. LATE FACE TO FACE ENCOUNTERS1. If the face-to-face encounter is not completedprior to the beginning of the 3rd or subsequentbenefit period (or on the first day or the period), itresults in failure to meet recertificationrequirements and the patient ceases to be eligiblefor the Medicare Hospice Benefit the day thebenefit period ended. The hospice discharges thepatient from Medicare as payor and continues tocare for the patient but the hospice assumesfinancial responsibility.2. Once the face-to-face encounter occurs, thefollowing must be completed to admit the patientback on the Medicare Hospice Benefit. Billing beginsagain the effective date of the election of benefits.a. Election of benefitb. Certification statement (and narrative) withnew benefit period datesc. Initial and comprehensive assessmentsd. Plan of carea. Although not a regulatory requirement, thenew Hospice should obtain a certification anda narrative from the hospice physicianregardless of where the patient is in theircurrent benefit period. The current benefitperiod does not change (i.e., benefit periodstays intact from the previous hospice).b. Hospice should obtain the previouscertifications, narratives and face-to-faceencounters to ensure they were completed.c. Refer to “Discharges, Transfers andRevocations” webpage for further guidance onthe transfer process beyond the certificationand recertification requirements.I. REFERENCESMedicare Benefit Policy Manual Chapter 9 - Coverageof Hospice Services Under Hospital Insurance 20Certification and Election Requirements; 20.1 - Timingand Content of Certification.Medicare Claims Processing Manual Chapter 11 Processing Hospice Claims 20.1.1 - Notice of Election(NOE), 20.1.3 - Change of Provider/Transfer Notice,30.3 - Data Required on the Institutional Claim to A/BMAC (HHH) MMedicare Program Integrity Manual (cms.gov) 3.3.2.4(D) - Signature Requirements1731 King StreetAlexandria, Virginia 22314Tel. 703-837-1500Medicare Hospice Certification and Recertification Compliance GuideNHPCO.ORG 07
The hospice medical director/hospice physician is more knowledgeable about the wording requirements in the narrative statement. Since only the hospice medical director/ hospice physician provides certification for the 2nd 90 day and all 60 day periods, this means only the hospice medical director/hospice physician will compose the narrative.
