Even though medically reviewed claims are selected with the purpose of determining medical necessity, these claims can be denied for technical reasons. Denials for an invalid Notice of Election (NOE) Statement and Physician's Certification can easily be avoided. This article provides tips to prevent these denials.
NOE Statement:
A valid Hospice NOE Statement must contain all of the following elements (CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20.2):
- Identification of the provider: The name of the particular hospice that will provide care to the beneficiary must appear on the election statement.
- An understanding of the nature of hospice care: The beneficiary or representative must acknowledge that he/she has been given a full understanding of the palliative rather than curative nature of hospice care.
- Waiver of certain Medicare benefits: The beneficiary or representative must acknowledge an understanding that the beneficiary has waived rights to other benefits when electing the hospice benefit for their illness.
- Effective date of election: The effective date of the election statement may be the first day of hospice care. Hospice care may start after the effective date, but not prior to the effective date.
- Signature: A dated signature of the beneficiary or representative must appear on the document.
There is no specific format for a NOE statement; however, all the required elements listed must be clearly evident for the NOE statement to be considered valid. If the acknowledgement of understanding of hospice care or the acknowledgement of waiving of the certain Medicare benefits is on a different page, send in both pages to medical review to support a valid NOE statement.
Commonly identified problems with NOE statements:
- No statement indicating the beneficiary fully understands the palliative rather than curative statement of the hospice benefit present in the medical record sent for review.
- No effective date present in the medical record sent for review.
- No waiver of certain Medicare benefits present in the medical record sent for review.
- The particular name of the individual hospice providing care is not identified. If the hospice belongs to a corporation or some other entity that has a different name, ensure the name of the particular hospice providing care is on the signed statement.
Hospice Physician Certification
A Hospice Physician Certification is a statutory requirement as indicated in the Social Security Act, Section 1814 (a)(7)(A) where the physician certifies that the beneficiary has a medical prognosis that the individual's life expectancy is six months or less if the terminal condition runs the normal course. There should be sufficient documentation the medical record substantiating the basis for the terminal illness.
A valid certification must contain the following elements:
- Prognosis Statement: There must be a statement proclaiming the beneficiary has a life expectancy of six months or less if the terminal illness runs the normal course.
- Start date of the benefit period: Each physician certification should coincide with the start of a new benefit period.
- Signed and dated physician signature: A dated physician signature or verbal certification from the physician must be obtained at the beginning of the benefit period which must be no later than two days from the start date of the benefit period.
- A valid verbal certification must contain the same elements as listed along with the name of the person receiving the verbal certification and the date the verbal order was obtained. The physician must sign the verbal certification prior to billing Medicare for payment.
- Certifications signed beyond two days from the start of the new benefit period (in the absence of a verbal certification) are considered valid from the date of the physician signature. No payment may be made for dates prior to the valid certification.
- Nurse practitioners or physician's assistants cannot sign a certification of terminal illness.
Initial certification
- The hospice medical director (or a physician member of the Interdisciplinary Group) and the beneficiary's attending physician must sign the certification of terminal illness. The agency should document when the medical director is serving as the attending physician.
- If a verbal certification is obtained, two separate entries are needed if the verbal certification is intended for two different physicians.
Re-certification
- The hospice medical director (or a physician member of the Interdisciplinary Group) must sign the recertification within two days of the start of the new benefit period. If unable to obtain the physician signature within two days, a verbal recertification should be obtained.
- The attending physician is not required to sign a re-certification.
The two PDF documents at the end of this article are the Elements Required for Physician Certification Checklist and examples of Physician Certification of Terminal Illness. To view or print this information, select the the PDF files below.