Comprehensive Error Rate Testing Details

Hospice Certification and Recertification

We have experienced an increasing number of CERT errors due to documentation requirements not being met. Below is the documentation required for hospice certification and recertification.

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 six months or less if the terminal illness runs its normal course.
  2. Specific clinical findings and other documentation supporting a life expectancy of six 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.
  4. As of 10/1/2009, the physician’s 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.
    • 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, 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 six months or less.
  5. Face-to-face encounter. For recertifications 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.

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Reviewed 11/14/2024