How to Prevent Denials Related to Physician Certification
In order to be eligible for hospice benefits under Medicare, the beneficiary must be certified as being terminally ill. The hospice must obtain a written certification of terminal illness for each benefit period.
- The hospice must include the written certification, to cover the dates of service billed, with the medical records submitted for review when responding to an Additional Documentation Request (ADR). All dates billed must be covered by a certification in order to be payable under the Medicare hospice benefit.
- If more than one certification covers the dates of service in question, submit all the related certifications for review
- For the first 90-day period of hospice coverage, the hospice must obtain, no later than two calendar days after hospice care is initiated (by the end of the third day), oral or written certification by the medical director or the physician member of the hospice interdisciplinary group and the beneficiary’s attending physician. If one physician is serving in both capacities, this must be clearly identified on the certification.
- Written certification must be on file in the hospice beneficiary’s record prior to submission of a claim to the Medicare contractor. If these requirements are not met, the payment begins with the day of certification
- If the written certification is not obtained within two calendar days, a verbal certification must be obtained within two calendar days, and the physician signature and date must be obtained before claim is submitted for payment
- The physician certification should include:
- Beneficiary name
- Six month prognosis statement
- Benefit period dates
- Physician(s) dated signature
- Name of staff member receiving the verbal certification and the date received (if applicable)
- For the first and second benefit periods, the physician must include a 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
- For the third and later benefit periods, the medical director or nurse practitioner must conduct a face-to-face encounter to validate the beneficiary’s need for hospice. The medical director or hospice physician must include a 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 prior to the physician’s signature and date. If the narrative exists as an addendum to the certification or recertification form, in addition to the physician’s signature and date on the certification or recertification form, the physician must also sign and date immediately following the narrative in the addendum.
- The narrative shall include a statement 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 narrative must reflect the patient’s individual circumstances and cannot contain check boxes or standard language used for all patients.
For more information, refer to:
- The Centers for Medicare & Medicaid Services (CMS) Internet-Only Manuals (IOMs), Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20.1 (PDF, 619 KB)
- Code of Federal Regulations, 42 CFR - Sections 418.200 (PDF, 181 KB)and 418.22 (PDF 187 KB)