Certification and Recertification
Introduction
The certification and recertification regulations require a physician certify the patient is terminally ill with a prognosis of 6 months or less should the disease run its normal course. There are very specific requirements on who can do this, the timing and the components (content, signatures, attestation, narrative and F2F) which must be addressed properly in order to submit a claim for all the days of care and eliminate risk for any technical denials by a medical review entity. Denials for technical reasons related to the certification and recertification process are one of the top denial reasons. This section provides resources and guidance on the initial certification, recertification, physician narrative and attestation and the Face to Face and attestation.
The hospice must obtain written certification of terminal illness for each period of hospice care received by an individual. For the initial 90-day period, the hospice must obtain written certification statements from the medical director of the hospice or the physician member of the hospice interdisciplinary group, and the individual's attending physician (if the individual has one). The certification must specify the individual's prognosis is for a life expectancy of six months or less if the terminal illness runs its normal course. Recertification for subsequent periods only requires the written certification by the hospice medical director or the physician member of the hospice interdisciplinary group. Certifications and recertifications must be dated and signed by the physician and must include the benefit periods to which they apply. Certifications and recertifications must include a brief narrative explanation of the clinical findings a life expectancy of six months or less.
If written certification is not obtained within 2 calendar days of the initiation of hospice care, a verbal certification must be obtained within the 2 days. A written certification from the medical director of the hospice or the physician member of the interdisciplinary group must be on file in the beneficiary's record prior to the submission of a claim to the Medicare contractor. If these requirements are not met, no payment may be made for the days prior to certification. Instead payment will begin with the day certification is obtained, i.e., the date verbal certification is obtained.
NHPCO Member Resources and Compliance Guides
Regulations
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- Hospice Care Code of Federal Regulations 42CFR 418
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Subpart B §418.22
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- 418.22 Certification of terminal illness
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Subpart D §418.102, §418.102
Subregulatory Guidance
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- Medicare Benefit Policy Manual Chapter 9 Medicare Benefit Policy Manual (cms.gov)
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20.1 - Timing and Content of Certification
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- Medicare Claims Processing Manual Chapter 11 - Processing Hospice Claim Medicare Claims Processing Manual (cms.gov)
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30.3 - Data Required on the Institutional Claim to A/B MAC (HHH) Untimely Face-to-Face Encounters and Discharge
60 - Certification and Recertification by Physicians for Hospice Care
3.3.2.4 (D)- Signature Requirements
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- MedLearn Matters article SE1628 Documentation Requirements for the Hospice Physician Certification/Recertification
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Other Resources
Cross Reference
Alerts/Newsbriefs/Newsline
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- NewsBriefs, June 10, 2021
Attestation: NHPCO asked whether the word “compose” should always be present in the attestation statement. The MACs confirmed that “compose” does not necessarily need to be included in the attestation statement, although the CMS sample attestation does include it. The MACs shared that the technical denials are often issued when there is NO attestation statement before the physician signature. The regulatory requirement is that the attestation confirm that the MD was the one composing the narrative.
- NewsBriefs, June 10, 2021
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Education
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- Webinars/On-Line Learning/Conferences
Nothing applicable at this time - Podcasts
Nothing applicable at this time
- Webinars/On-Line Learning/Conferences
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Marketplace
The NHPCO Certification and Recertification of Hospice Terminal Illness process maps describe the certification and recertification process, with special attention given to the face to face encounter requirement. The maps and tables are designed to guide the admission team, hospice physician, nurse practitioner through the process of certification and recertification no matter what benefit the patient is in. Use the Master Process Map as a guide to determine which map fits the patient's admission and certification, whether the patient is new to your hospice or is transferring from another hospice provider.
Medicare has very specific requirements on what constitutes a valid signature for medical review purposes. The Medicare Hospice Benefit has specific requirements for the signature and attestations for the certification/recertification and face to face requirements. A hospice must follow all requirement in order to submit a valid claim.
NHPCO Member Resources and Compliance Guides
Regulations
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- Hospice Care Code of Federal Regulations 42CFR 418
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Subpart B §418.22
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- 418.22 Certification of terminal illness
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Subregulatory Guidance
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- Medicare Program Integrity Manual (cms.gov)
3.3.2.4 (D) - Signature Requirements - MLN Signature Requirements Fact Sheet
- Medicare Program Integrity Manual (cms.gov)
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Other Resources
Cross Reference
Alerts/Newsbriefs/Newsline
Nothing applicable at this time
Education
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- Webinars/On-Line Learning/Conferences
Nothing applicable at this time - Podcasts
Nothing applicable at this time
- Webinars/On-Line Learning/Conferences
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Marketplace
Nothing applicable at this time
Beginning June 3, 2024, for Medicare to pay for hospice services, a physician must be enrolled in or validly opted-out of Medicare in order to certify a patient’s terminal illness under the Medicare hospice benefit. This requirement applies to:
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- the hospice medical director or the physician member of the hospice interdisciplinary group, and attending physician (if any), who certifies a patient’s terminal condition.
- both written and oral certifications under the Medicare hospice benefit.
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The Centers for Medicare & Medicaid Services (CMS) has clarified that physicians need only be enrolled or opted-out at the time they certify or recertify a patient’s terminal illness. “The hospice physician and attending physician need only be enrolled/opted-out at the time they make the certification or recertification. They need not remain enrolled/opted-out during the patient’s entire certification and benefit period and, if they become unenrolled and non-opted out, the hospice need not secure a new certification to replace the one the previously enrolled/opted-out physician signed.” 88 Fed. Reg. 51164 at 51190.
CMS finalized this requirement in the fiscal year (FY) 2024 Hospice Wage Index and Payment Rate Update final rule in the goal to increase oversight over physicians who are certifying hospice services and to better prevent fraud, waste, and abuse under the Medicare program. CMS believes this requirement will help determine whether a physician presents any program integrity risks and could help foster beneficiary health and safety by ensuring physicians are appropriately licensed when certifying a patient’s terminal condition under the hospice benefit.
Implementation Date
CMS has extended the implementation date from May 1, 2024 to June 3, 2024 for this physician enrollment requirement. Unenrolled and non-opted out hospice and attending physicians will need to enroll or opt-out of Medicare before the denial of hospice claims commences on June 3, 2024, according to 42 CFR § 424.507(b).
Medicare Enrollment
To enroll in Medicare, physicians may complete and submit the appropriate enrollment application, Form CMS-855, to the Part B Medicare Administrative Contractor (MAC) for their region. This application includes:
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- The CMS-855I (PDF) form is for physicians and non-physician practitioners who want to bill Medicare for services. (NOTE: If the physician will not bill Medicare Part B for services and only Part A hospice services are involved, the physician cannot enroll via the Form CMS-855I).
- The CMS-855O (PDF) form is for physicians and non-physician practitioners who only want to order and certify services under Medicare.
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This application may be submitted via paper or electronically through the internet-based Provider Enrollment, Chain, and Ownership System (PECOS). After receiving the enrollment application, the MAC and CMS will review the application to determine whether the physician, provider, or supplier meets all applicable Medicare requirements.
Physicians and providers may also check in with their MAC regarding their enrollment status - Contact Your MAC (PDF).
Opting Out of Medicare
Physicians may complete an Opt-Out Affidavit Form (available from the respective MAC) to validly opt-out of Medicare services. A physician who has validly opted-out of Medicare may still certify a patient’s terminal illness under the Medicare hospice benefit. However, a hospice cannot bill for hospice physician services if the physician has opted out of Medicare.
Non-Physician Practitioners Serving as the Attending Physician
The requirement to be enrolled or validly opted-out of Medicare does not apply to nurse practitioners and physician assistants serving as a patient’s attending physician. This is because only physicians may certify hospice services under the Medicare benefit.
Physician Enrollment Verification
CMS has indicated hospices should refer to the Ordering and Referring Data File (ORDF) to determine a physician’s Medicare enrollment or opt-out status. CMS has indicated the ORDF will be updated to include a column for hospices, similar to existing columns for DMEPOS and HHAs). The ORDF can be found on the CMS data website.
NHPCO Member Resources and Compliance Guides
Regulations
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- 42 CFR 424.507(b), Conditions for payment of claims for covered home health and hospice services
- 42 CFR 418.22, Certification of terminal illness
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Subregulatory Guidance
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- CMS Hospice Certifying Enrollment Questions and Answers (Q & A) Document (5/26/24)
- MLN Matters Article MM13531, Hospice Claims Edits for Certifying Physicians (05/10/24)
- CMS MLN Connects Newsletter Message, Implement Edits on Hospice Claims (5/09/24)
- CMS Hospice Medicare Learning Network Update (3/26/24)
- CMS Change Request 13342 (10/26/23)
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Other Resources
Cross Reference
Alerts/NewsBriefs/Newsline
Education
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- Webinars/On-Line Learning/Conferences
Nothing applicable at this time
- Webinars/On-Line Learning/Conferences
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- Podcasts
Nothing applicable at this time
- Podcasts
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Marketplace
Nothing applicable at this time