Hospice Certification / Recertification Requirements
Policy Manual (CMS Pub. 100-02), Ch. 9, §20.1
In order for a patient to be eligible for the Medicare hospice benefit, the
patient must be certified as being terminally ill. An individual is considered
to be terminally ill if the medical prognosis is that the individual’s
life expectancy is 6 months or less if the illness runs its normal course.
The certification/recertification is a critical piece of documentation necessary
to ensure Medicare payment for the hospice services you provide.
Timeframe for Certification/Recertification
The hospice must obtain verbal or written certification of
the terminal illness, no later than 2 calendar days (by
the end of the third day) after the start of each benefit period (initial and
subsequent). Initial certifications may be completed up to 15 days
before hospice care is elected. Recertifications may be completed up
to 15 days before the start of the next benefit period.
If written certification/recertification cannot be obtained within 2 calendar
days, verbal certification must be obtained. The hospice must determine who
may accept verbal certification from a physician in compliance with state and
local law regulations.
In addition, the hospice must ensure the written certification/recertification
is signed and dated prior to billing Medicare, or their claim(s) may be denied.
Content of the Certification/Recertification
The certification should be based on the clinical judgment of the hospice
medical director (or physician member of the interdisciplinary group (IDG),
and the patient’s attending physician, if he/she has one.
In addition to the initial certification for hospice, the patient must be
recertified for each subsequent hospice benefit period.
The written certification/recertification must include:
- The statement that the patient’s medical prognosis is that their
life expectancy is 6 months or less if the terminal illness runs its normal
- A brief narrative, written by the certifying physician, explaining the
clinical findings that support the patient’s life expectancy of six
months or less. This narrative can be a part of the certification/recertification
form or as an addendum to the form.
- If the narrative is part of the form, it must be located immediately
above the physician’s signature.
- If the narrative is an addendum, the physician must also sign the addendum
immediately following the narrative.
- Do not include check boxes or standard language used for all patients.
The narrative cannot be completed by other hospice personnel; it must be
completed by the certifying physician.
- The narrative shall include a statement, located above the physician
signature and date, that attests to the fact that by signing the form,
the physician confirms that he/she composed the narrative based on his/her
review of the patient’s medical record or his/her examination of
- The benefit period dates that the certification or recertification covers.
- Effective for recertifications on/after January 1, 2011, narratives associated
with the third benefit period and subsequent benefit periods must explain
why the clinical findings of the face-to-face encounter support a life expectancy
of six months or less. Documentation must include the date of the encounter,
an attestation by the physician or nurse practitioner that he/she had an
encounter with the beneficiary. If the encounter was done by a nurse practitioner,
he/she must attest that clinical findings were provided to the certifying
Signature Requirements for Certification
Policy Manual (CMS Pub. 100-02), Ch. 9, §20.1
Integrity Manual (CMS Pub. 100-08), Ch. 3, §18.104.22.168
- Handwritten signatures
- Electronic signatures
- Facsimile of original written or electronic signatures
Signatures for Initial Certifications:
For the first benefit period after election of the Medicare hospice benefit,
the certification must be signed and dated by the:
- Medical director of the hospice or the physician member of the hospice
interdisciplinary group (IDG); and
- The beneficiary’s attending physician (if they have one).
Note: To sign the certification, the attending physician must be a doctor
of medicine or osteopathy, and be identified by the beneficiary at the time
he/she elects to receive hospice care as having the most significant role in
the determination and delivery of the individual’s medical care.
Signatures for Recertifications:
For the recertification (for subsequent hospice benefit periods), only the
hospice medical director or the physician member of the IDG is required to
sign and date the certification. The beneficiary’s attending physician
is not required to sign and date the recertification.
Common Hospice Certification Errors
Medicare cannot make appropriate payment without correct dates, signatures
and identifying roles of the physician(s). The following list identifies the
common types of missing and inadequate information:
- Predating physician(s) certification signatures
- Not having both the hospice medical director and attending physician (if
applicable) sign the initial certification as required
- The physician narrative is missing
- The physician’s narrative does not include a statement attesting that it was composed by the physician
- The attestation statement is missing
- Not having verbal certifications by both the medical director and attending
physician (if applicable)
- No physician(s) signatures
- Illegible physician signatures
- Physician did not date his/her signature
- Not clearly stating the dates the certification period encompasses