Mont. Medicaid Hospice Policy Manual, Policy 403

CERTIFICATION OF

TERMINAL ILLNESS

➢For the first 90-day period of hospice coverage, the hospice must

obtain, no later than two calendar days after hospice care is

initiated, (that is, by the end of the third day), oral or written

certification of the terminal illness by the medical director of the

hospice or the physician member of the hospice Interdisciplinary

Group (IDG), and the individual’s attending physician if the

individual has an attending physician.

No one other than a medical doctor or doctor of osteopathy can

certify or re-certify an individual as terminally ill, meaning that the

individual has a medical prognosis that his or her life expectancy is

six months or less if the illness runs its normal course. Nurse

practitioners and physician assistants cannot certify or re-certify an

individual as terminally ill. In the event that a beneficiary’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.

Hospice providers must obtain written certification of terminal

illness for each hospice benefit election period.

Certification must be obtained even if a single election continues in

effect for an unlimited number of periods.

The hospice must obtain the written certification before it submits a

claim for payment except in the following circumstances:

1. If the hospice cannot obtain the written certification

within two calendar days, after a period begins, it

must obtain an oral certification within two calendar

days and the written certification before it submits a

claim for payment.

2. Certifications may not be completed more than fifteen

calendar days prior to the effective date of hospice

election.

3. Recertification may not be completed more than

fifteen calendar days prior to the subsequent benefit

period.

Face-to-Face (F-T-F)

ENCOUNTERS

➢A hospice physician or hospice nurse practitioner must have an

F-T-F encounter with each hospice member whose total stay

across all hospices is anticipated to reach the third benefit period.

NOTE: Physician Assistants may not perform the

F-T-F encounter.

The F-T-F encounter must occur prior to, but no more than 30

calendar days prior to:

1. Third benefit period recertification, and

2. Every benefit period recertification thereafter.

The F-T-F encounter will be used to gather clinical findings to

determine continued eligibility for hospice care.

Hospice may conduct F-T-F encounters as part of the certification

process.

Failure to meet the F-T-F encounter requirements specified in this

section results in a failure by the hospice to meet the member’s

recertification of terminal illness eligibility requirement.

CONTENT OF

CERTIFICATION

Certification will be based on the attending physician or medical

director’s clinical judgement regarding the normal course of the

member’s illness. The certification must conform to the following:

1. The certification must specify that the member’s

prognosis is for a life expectancy of six months or less

if the illness runs its normal course;

2. Clinical information and other documentation that

supports the medical prognosis must accompany the

certification and must be filed in the medical record

with the certification.

NOTE: Initially the clinical information

must be provided verbally, and

must be documented in the

medical record and included as

part of the hospice’s eligibility

assessment.

3. The physician must include a brief narrative

explanation of the clinical findings that supports a life

expectancy of six months or less as part of the

certification and recertification forms, or as an

addendum to the certification and recertification

forms:

a. If the narrative is part of the certification

or recertification form, then the narrative

must be located immediately prior to the

physician’s signature;

b. If the narrative exists as an addendum

to the certification or recertification form,

in addition to the physician’s signature

on the certification or recertification

form, the physician must also sign

immediately following the narrative in

the addendum;

c. The narrative shall include a statement

directly above the physician’s signature

attesting that by signing, the physician

confirms that the physician composed

the narrative based on his/her review of

the member’s medical record or, if

applicable, the physician’s examination

of the member;

d. The narrative must reflect the member’s

clinical circumstances and cannot

contain check boxes or standard

language used for all members; and

e. The narrative associated with the third

benefit period recertification and every

subsequent recertification must include

an explanation of why the clinical

findings of the F-T-F encounter support

a life expectancy of 6 months or less.

4. The physician who performs the F-T-F encounter with

the member must attest in writing that he or she has a

F-T-F encounter with the member, including the date

of the visit;

5. The attestation of the non-certifying hospice physician

shall state that the clinical findings of that visit were

provided to the certifying physician for use in

determining continued eligibility for hospice care; and

6. All certifications and recertifications must be signed

and dated by the physician(s), and must include the

benefit period dates to which the certification or

recertification applies.

SOURCES OF

CERTIFICATIONS

For the initial 90-day period, the hospice must obtain written

certification statements (and oral certification statements if

required) from:

1. The medical director of the hospice or the physician

member of the hospice interdisciplinary group; and

2. The member’s attending physician, if the member has

an attending physician. The attending physician must

meet the definition of physician specified in

37.40.801, (Refer to Hospice Policy 003).

For subsequent periods, the only requirement for certification is by

one of the physicians specified.

MAINTENANCE

OF RECORD

Hospice staff must:

1. Make an appropriate entry in the member’s medical

record as soon as they receive an oral certification;

and

2. File written certifications in the medical record.