Ga. Medicaid Part II Policies & Procedures for Hospice Services § 704

The hospice agency must obtain certification that an individual is terminally ill in accordance with

the procedures outlined. Hospice providers and certifying physicians may not use Debility and AFTT

as the primary diagnosis cited as cause for the terminal illness. ‘‘Symptoms, Signs, and Ill-defined

Conditions” may not be used as principal diagnoses for a hospice member. The principal diagnosis

must be the definitive condition determined by the certifying hospice physician(s) as the diagnosis

contributory to the member’s terminal decline. Symptoms, Signs, and Ill-defined Conditions are

considered secondary or tertiary to the principal definitive diagnosis.

Effective 11/01/2013, election and certification forms that have a primary diagnosis of Symptoms,

Signs, and Ill-defined Conditions including, Unspecified Dementia, Debility and/ or Adult Failure to

Thrive will not be processed for the hospice member lock-in and will be returned to the provider by

the fiscal agent, Gainwell Technologies.

Effective 10/01/2014, the Department will apply these rules to claims processing and deny any claim

with a diagnosis that is considered a Symptom, Sign, or Ill-defined Condition. Symptoms, Signs and

Ill-defined Conditions are any diagnoses classified as non-billable ICD-10 codes by Medicare. As

classified by Medicare, the Unspecified Dementia ICD-10 codes are also non-billable codes.

Effective 10/1/2015, providers must enter the ICD-10 CM code. All codes must be cross walked to

ICD-10 codes. (Do not bill ICD- 9 code sets on or after October 1, 2015.)

The hospice agency must have the physician certification of terminal illness completed for patient’s

file per established Division policy before submitting the election form and claims for

reimbursement. The Division does not require submission of the physician certification of terminal

illness for the initial lock-in of the member except for a request by the Division to make the form

available for review when the election form is sent in more than 90 days of the initial election or

within other circumstances that a request is made.

The Division requires that the provider make available the certification form(s) for all subsequent

extension span requests to the fiscal agent. When the member is entering the 6th Hospice Benefit

Period (thru the 360th days of Gainwell Technologies’s system election span) submit all Physician’s

Certification Form(s) (ALL F2F encounter attestations) with the terminal illness diagnosis and the

current Plan of Care (showing coordinated care if applicable) to Gainwell Technologies so that the

hospice provider lock-in can be extended. Failure to meet the F2F encounter timeframes results in a

failure by the hospice provider to certify the patient’s terminal illness. This means that the patient

would not be eligible for the Medicaid Hospice Benefit or for Medicaid reimbursement. The

certification documentation must be submitted within the 30 days prior to the expiration of the

current span. The hospice providers may submit to Gainwell Technologies the Medicaid Hospice

Physician Certification Form (See Appendix C), or a physician certification form used internally by

the hospice agency or the Medicare Hospice Physician Certification Form. The Medicare Physician

certification forms are required to remain on file for the dually eligible Medicare and Medicaid NF

residents.

Note: Currently, when the member is entering the 6th Hospice Benefit Period (thru the 360th days of

Gainwell Technologies’s system election span) submit all Physician’s Certification Form(s) (ALL

F2F encounter attestations [see .1C]) with the terminal illness diagnosis and the current Plan of

Care (showing coordinated care if applicable) to Gainwell Technologies so that the hospice provider

lock-in can be extended. Failure to meet the F2F encounter timeframes results in a failure by the

hospice provider to certify the patient’s terminal illness. This means that the patient would not be

eligible for the Medicaid Hospice Benefit or for Medicaid reimbursement. The certification

documentation must be submitted within the 30 days prior to the expiration of the current span.

The hospice agency must fax a Hospice Care Communicator Form to DFCS indicating the initial or

subsequent certification periods within the appropriate timeframes for individuals that have elected

Hospice.

704.1. For the first election of hospice coverage, the hospice agency must obtain no later than

two (2) calendar days after hospice care is initiated written certification statements

signed by the medical director of the hospice agency or the physician member of the

hospice agency interdisciplinary group and the individual’s attending physician.

704.2. If the hospice agency cannot obtain a written certification within two (2) calendar days

after the initiation of hospice care, a verbal certification must be obtained within these

two (2) calendars days and a written certification obtained no later than eight (8)

calendar days after care is initiated. A notation must be made on the physician

certification form to indicate the attainment of the verbal certification. The notation

must include the date the certification was received and the date, signature and

title/position of the person who received the verbal certification.

704.2.1. Reimbursement will not be made for any days of hospice care prior to

the certification date. See Appendix M regarding additional information

for Medicaid claim reimbursement.

704.2.2. Certifications for the initial election of hospice coverage may be

completed up to two (2) weeks prior to the election of hospice care. Two

(2) weeks is defined as fourteen (14) calendar days.

704.2.3. The attending physician is a physician who is a Doctor of Medicine or

osteopathy and is identified by the individual at the time of election to

receive hospice care as having the most significant role in the

determination and delivery of the individual’s medical care.

704.2.4. Physicians may not delegate the initial certification process to a nurse

practitioner. Nurse Practitioners may not certify terminal illness with a

prognosis of 6 months or less for initial or subsequent.

704.2.5. Effective November 1, 2013, the hospice-employed physician or the

hospice-employed nurse practitioner (NP) must have a face-to- face

(F2F) encounter prior to the 180th day certification period. This face- to-face assessment is required prior to the beginning of the patient’s third

(3rd) benefit period and prior to each subsequent benefit period thereafter

to determine continued eligibility of the individual for hospice care and

attest that such a visit took place.

704.3. For all subsequent benefit periods, the hospice agency must obtain a written

certification statement prepared by the medical director of the hospice agency or the

physician member of the hospice agency interdisciplinary group to keep on file.

Certifications for the subsequent hospice benefit periods may be completed up to

fourteen (14) calendar days prior to the beginning of the subsequent period but cannot

be obtained later than eight (8) calendar days after the beginning of the benefit period.

704.3.1. Effective November 1, 2013, the hospice-employed physician or the

hospice-employed nurse practitioner (NP) must have a face-to- face

encounter prior to the 180th day certification period. This face-to- face

assessment is required prior to the beginning of the patient’s third (3rd)

benefit period and prior to each subsequent benefit period thereafter to

determine continued eligibility of the individual for hospice care and

attest that such a visit took place.

704.3.2. The face-to-face encounter should not be more than 30 days prior to the

benefit period being recertified by the physician.

704.3.3. The physician who performs the encounter must attest in writing that he

or she had a face-to-face encounter with the patient, including the date of

the encounter, and indicate the clinical findings of that visit for use in

determining continued eligibility for hospice care.

704.3.4. When the hospice NP performs the encounter, the attestation must state

that the findings of that visit were provided to the certifying physician

for use in determining whether the patient continues to have a life

expectancy of 6 months or less should the illness run its normal course.

704.3.5. Both the physician’s certification narrative and the F2F encounter

attestation MUST remain on file for auditors to review.

704.3.6. The attestation must be clearly titled, its accompanying signature, and the

date signed, must be on a separate and distinct section of, or an

addendum to, the certification form.

704.3.7. If the attestation is included on the certification, it must be located above

the physician’s signature.

704.3.8. Where both the encounter attestation and narrative are included as an

addendum to the certification, one physician signature can suffice for

both the narrative and attestation.

704.3.9. Both the narrative and the attestation must be located above the

physician’s signature.

704.3.10. Failure to meet the encounter timeframes results in a failure by the

hospice provider to meet the patient’s certification eligibility

requirement. This means that the hospice provider will not be eligible for

Medicaid reimbursement for this member.

704.3.11. Providers must submit the election and certification forms to Gainwell

Technologies for the initial election and for the certification lock-in time

span within the 30-day time limit to receive Medicaid reimbursement.

704.3.12. Failure by hospice providers to coordinate the member’s care with

services being rendered by the member’s other Medicaid providers as

allowed by policy will be considered non-compliant and all hospice

services rendered to that member will be subject to recoupment.

704.3.13. The coordinated plan or care for the hospice patient that is a member of

another Medicaid program must be available in the member’s record for

the duration of all hospice election periods.

704.3.14. Documentation to support the terminal prognosis must be maintained in

the individual’s medical record. The documentation must include, where

applicable, the following:

704.3.14.1. Terminal diagnosis and all related conditions present at

the time of enrollment.

704.3.14.2. Physician documentation, laboratory, radiological or

other studies.

704.3.14.3. Clinical progression of the terminal disease.

704.3.14.4. Recent decline in functional status.

704.3.14.5. Supporting documentation that indicates the individual

has entered an end-state of a chronic disease.

704.3.15. The hospice agency must retain the documentation in the individual’s

record in accordance with Georgia statute of limitation requirements.

704.3.16. The Division may request the documentation of the terminal prognosis

for clarification or review as needed.

704.4. The hospice agency must retain the Medicare and/ or Medicaid certification statements

in the individual’s record in accordance with Georgia statute of limitation requirements.

If required for research, reimbursement, or other purposes, the Division will request the

hospice agency to submit all copies of the signed physician certification statements.

704.5. An entry on the Certification form must be made to note the exception when the

medical director or physician member of the hospice agency interdisciplinary group

services as the attending physician.

704.6. Stamped physician signatures are not acceptable on the certification form.

704.7. When the physician’s signature is not dated, the hospice agency must stamp the

certification form with the date the form is received by the hospice agency. If the

stamped date of receipt of the certification by the hospice agency is outside the

established time frame for obtaining physician certifications, the Division will not

reimburse the agency for days of hospice care prior to the physician certification. If the

stamped date of receipt of the certification by the hospice agency is within the

established time frame for obtaining physician certifications, reimbursement will be

made for all covered days of hospice service.