Medi-Cal Provider Manual, Part 2, Hospice Care, Medical Member Certification of Terminal Illness/Recertification Required

Attending physicians (if applicable) and medical directors or physicians who are part of the

hospice interdisciplinary team must have certified in writing at the beginning of the first

90-day period that Medi-Cal members were terminally ill, which is identified with one or more

clinically appropriate ICD-10-CM diagnosis codes.

For all subsequent recertification periods, only hospice providers, which can include a

physician or the hospice medical director, may certify that Medi-Cal members are terminally

ill with six months or less to live.

At the start of the first 90-day period of care, hospice providers must maintain an initial

certification of terminally illness in Medi-Cal members’ medical records. At the start of each

subsequent period of care, hospice providers must maintain a recertification of terminal

illness in Medi-Cal members’ medical record.

All of this information must be made available to DHCS upon request and in the event of a

state or federal audit.

Example:

A Medi-Cal member has an end-stage liver disease, and her attending physician told her

she has six months to live. The Medi-Cal member elects hospice in lieu of curative treatment

and completes the required election forms and her attending physician and the hospice

medical director certifies she is terminally ill. The Medi-Cal member elects hospice on

September 1, 2009, and begins receiving hospice care.

• Initial certification: September 1, 2009, through November 29, 2009 (first 90-day

period). The Medi-Cal member remains alive, and the hospice medical director certifies

her again as terminally ill. The hospice provider must maintain the certification that the

Medi-Cal member is terminally ill in the Medi-Cal member’s medical record.

• Recertification: November 30, 2009, through February 27, 2010 (second 90-day

period). The Medi-Cal member continues to live, and the hospice medical director

certifies her again as terminally ill. The hospice provider must maintain the

recertification that the Medi-Cal member is terminally ill in the Medi-Cal member’s

medical record.

• Recertification: February 28, 2010, and again April 29, 2010, etc. (60-day periods,

unlimited. Every 60 days the hospice medical director must certify that the Medi-Cal

member is terminally ill. The hospice provider must maintain the certification that the

Medi-Cal member is terminally ill in the Medi-Cal member’s medical record.

Face-To-Face Encounter

Hospice physicians or nurse practitioners (NP) are required to have a face-to-face encounter

with all Medi-Cal members receiving hospice services to determine their continued eligibility.

The face-to-face encounter requirement is satisfied when the following criteria are met:

• Timeframe of the encounter: The encounter must occur no more than 30 calendar

days prior to the start of the third benefit period, and no more than 30 calendar days

prior to every subsequent benefit period thereafter (refer to item four below for an

exception to this timeframe).

• Attestation requirements: Hospice physicians or NPs who perform the encounter must

attest in writing that they had a face-to-face encounter with Medi-Cal members,

including the date of the encounter. The attestation, its accompanying signature, and

the date signed must be a separate and distinct section of, or an addendum to, the

recertification form, and must be clearly titled. Where NPs perform the encounter, the

attestation must state that the clinical findings of that visit were provided to the

certifying physician for use in determining whether Medi-Cal members continue to

have a life expectancy of six months or less, should the illness run its normal course.

• Practitioners who can perform the encounter: Hospice physicians, who are employed

by the hospice or working under contract with the hospice, or hospice NPs, who are

employed by the hospice, can perform the encounter. Hospice employees are

defined as those who receive a W-2 from the hospice or who volunteer for the

hospice.

• Timeframe exceptional circumstances for new hospice admissions in the third or later

benefit period: In cases where a hospice newly admits Medi-Cal members in the third

or later benefit period, exceptional circumstances may prevent a face-to-face

encounter prior to the start of the benefit period. For example, if Medi-Cal members

are an emergency weekend admission, it may be impossible for hospice physicians

or NPs to see them until the following Monday. Or, if federal CMS data systems are

unavailable, hospice providers may be unaware that Medi-Cal members are in the

third benefit period. In such documented cases, a face-to-face encounter that occurs

within two days after admission will be considered timely. Additionally, for such

documented exceptional cases, if Medi-Cal members die within two days of

admission without a face-to-face encounter, a face-to-face encounter can be deemed

complete.

• Timeframe requirements when Medi-Cal members transfer from one hospice to

another: When Medi-Cal members transfer from one hospice to another, it is

sometimes difficult to determine the current benefit period. In such cases, receiving

hospice providers may not know if a face-to-face recertification is necessary.

Receiving hospice providers are required to document in Medi-Cal members’ medical

records all efforts to obtain the previous hospice benefit period, either from the

transferring hospice provider or from other sources. If receiving hospice providers

cannot determine the current benefit period, the face-to-face recertification clock

starts from the time receiving hospice providers complete the intake process. This

information, along with all certification statements, must be maintained in Medi-Cal

members’ medical records and be available to DHCS upon request or in the event of

a state or federal audit.