CMS Pub. 100-02, ch. 9, § 20

A3-3141, HO-204

20.1 - Timing and Content of Certification

(Rev: 13664; Issued: 03-05-26; Effective: 10-01-25; Implementation: 04-06-26)

For the first 90-day period of hospice coverage, the hospice must obtain, no later than 2

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 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 6 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.

The attending physician is a doctor of medicine or osteopathy who is legally authorized

to practice medicine or surgery by the state in which he or she performs that function, a

nurse practitioner, or physician assistant, and is identified by the individual, at the time he

or she elects to receive hospice care, as having the most significant role in the

determination and delivery of the individual’s medical care. A nurse practitioner is

defined as a registered nurse who performs such services as legally authorized to perform

(in the state in which the services are performed) in accordance with State law (or State

regulatory mechanism provided by State law) and who meets training, education, and

experience requirements described in 42 CFR 410.75. A PA is defined as a professional

who has graduated from an accredited physician assistant educational program who

performs such services as he or she is legally authorized to perform (in the State in which

the services are performed) in accordance with State law (or State regulatory mechanism

provided by State law) and who meets the training, education, and experience

requirements as the Secretary may prescribe. The PA qualifications for eligibility for

furnishing services under the Medicare program can be found in the regulations at 42

CFR 410.74 (c).

Note that a rural health clinic (RHC) or federally qualified health center (FQHC)

physician can be the patient’s attending physician. Refer to Chapter 13, section 210 for

more information.

Initial certifications may be completed up to 15 days before hospice care is elected.

Payment normally begins with the effective date of election, which is the same as the

admission date. If the physician forgets to date the certification, a notarized statement or

some other acceptable documentation can be obtained to verify when the certification

was obtained.

For the subsequent periods, recertifications may be completed up to 15 days before the

next benefit period begins. For subsequent periods, the hospice must obtain, no later than

2 calendar days after the first day of each period, a written certification statement from

the medical director of the hospice or the physician member of the hospice’s IDG. If the

hospice cannot obtain written certification within 2 calendar days, it must obtain oral

certification within 2 calendar days. When making an oral certification, the certifying

physician(s) should state that the patient is terminally ill, with a prognosis of 6 months or

less. Because oral certifications are an interim step sometimes needed while all the

necessary documentation for the written certification is gathered, it is not necessary for

the physician to sign the oral certification. Hospice staff must make an appropriate entry

in the patient's medical record as soon as they receive an oral certification.

The hospice must obtain written certification of terminal illness for each benefit period,

even if a single election continues in effect. A written certification must be on file in the

hospice patient’s record prior to submission of a claim to the Medicare contractor.

Clinical information and other documentation that support the medical prognosis must

accompany the certification and must be filed in the medical record with the written

certification. Initially, the clinical information may be provided verbally, and must be

documented in the medical record and included as part of the hospice's eligibility

assessment.

A complete written certification must include:

1. the statement that the individual’s medical prognosis is that their life expectancy is 6

months or less if the terminal illness runs its normal course;

2. specific clinical findings and other documentation supporting a life expectancy of 6

months or less;

3. the signature(s) of the physician(s), the date signed, and the benefit period dates that

the certification or recertification covers (for more on signature requirements, see Pub.

100-08, Medicare Program Integrity Manual, chapter 3, section 3.3.2.4).

4. as of October 1, 2009, the physician’s brief narrative explanation of the clinical

findings that supports a life expectancy of 6 months or less as part of the certification and

recertification forms, or as an addendum to the certification and recertification forms;

If the narrative is part of the certification or recertification form, then the narrative must

be located immediately above the physician’s signature.

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.

The narrative shall include a statement directly above the physician signature attesting

that by signing, the physician confirms that he/she composed the narrative based on

his/her review of the patient’s medical record or, if applicable, his or her examination of

the patient. The physician may dictate the narrative.

The narrative must reflect the patient’s individual clinical circumstances and cannot

contain check boxes or standard language used for all patients. The physician must

synthesize the patient’s comprehensive medical information in order to compose this

brief clinical justification narrative.

For recertifications on or after January 1, 2011, the narrative associated with the third

benefit period recertification and every subsequent recertification must include an

explanation of why the clinical findings of the face-to-face encounter support a life

expectancy of 6 months or less.

5. face-to-face encounter. For recertifications on or after January 1, 2011, a hospice

physician or hospice nurse practitioner must have a face-to-face encounter with each

hospice patient prior to the beginning of the patient’s third benefit period, and prior to

each subsequent benefit period. Failure to meet the face-to-face encounter requirements

specified in this section results in a failure by the hospice to meet the patient’s

recertification of terminal illness eligibility requirement. The patient would cease to be

eligible for the benefit.

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

a. Timeframe of the encounter: The encounter must occur prior to the recertification for

the third benefit period and each subsequent benefit period. The encounter must occur no

more than 30 calendar days before the third benefit period recertification and each

subsequent recertification. A face-to-face encounter may occur on the first day of the

benefit period and still be considered timely. (Refer to section 20.1.5.d below for an

exception to this timeframe).

b. Attestation requirements: A hospice physician or nurse practitioner 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. The attestation, its accompanying signature,

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

recertification form, and must be clearly titled. The attestation requirement may also be

fulfilled by not only a clearly titled section of or an addendum to the recertification form,

but also by a signed and dated clinical note within the medical record that documents

clear indication that the face-to-face encounter occurred and includes the date of the

visit, the signature of the practitioner who conducted the face-to-face encounter, and the

date of the signature. Where a nurse practitioner or noncertifying hospice physician

performed the encounter, and the attestation is a separate and distinct section of, or an

addendum to, the recertification, the attestation must state that the clinical 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.

c. Practitioners who can perform the encounter: A hospice physician or a hospice nurse

practitioner can perform the encounter. A hospice physician is a physician who is

employed by the hospice or working under contract with the hospice. A hospice nurse

practitioner must be employed by the hospice. A hospice employee is one who receives a

W-2 from the hospice or who volunteers for the hospice. If the hospice is a subdivision

of an agency or organization, an employee of that agency or organization assigned to the

hospice is also considered a hospice employee. Physician Assistants (PAs), clinical nurse

specialists, and outside attending physicians are not authorized by section

1814(a)(7)(D)(i) of the Act to perform the face-to-face encounter for recertification.

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

benefit period: In cases where a hospice newly admits a patient who is 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 the patient is an emergency weekend

admission, it may be impossible for a hospice physician or NP to see the patient until the

following Monday. Or, if CMS data systems are unavailable, the hospice may be

unaware that the patient is in the third benefit period. In such documented cases, a face

to face encounter which occurs within 2 days after admission will be considered to be

timely. Additionally, for such documented exceptional cases, if the patient dies within 2

days of admission without a face to face encounter, a face to face encounter can be

deemed as complete.

Recertifications that require a face-to-face encounter but which are missing the encounter

are not complete. The statute requires a complete certification or recertification in order

for Medicare to cover and pay for hospice services. Where the only reason the patient

ceases to be eligible for the Medicare hospice benefit is the hospice’s failure to meet the

face-to-face requirement, Medicare would expect the hospice to discharge the patient

from the Medicare hospice benefit, but to continue to care for the patient at its own

expense until the required encounter occurs, enabling the hospice to re-establish

Medicare eligibility. The hospice can re-admit the patient to the Medicare hospice

benefit once the required encounter occurs, provided the patient continues to meet all of

the eligibility requirements and the patient (or representative) files an election statement

in accordance with CMS regulations.

The hospice must file written certification statements and retain them in the medical

record. Hospice staff must make an appropriate entry in the patient's medical record as

soon as they receive an oral certification.

These requirements also apply to individuals who had been previously discharged during

a benefit period and are being recertified for hospice care.