Hospice Certification Form How-to

Unclear about exactly what information a Medicare hospice certification or recertification form must contain?

The Centers for Medicare & Medicaid Services (CMS) offers guidance on these essential elements the form must have:

  • The statement that the individual’s medical prognosis is that the beneficiary’s life expectancy is six months or less if the terminal illness runs its normal course;
  • The physician’s brief narrative explanation of patient-specific clinical findings that supports a life expectancy of six months or less.
    • The narrative should conclude with a statement attesting that by signing, the physician confirms that he/she composed the narrative based on his or her review of the patient’s medical record or, if applicable, his or her examination of the patient.
    • The narrative can be part of the certification and recertification form or an addendum to the form. 
  • The signature(s) of the physician(s), the date signed, and the benefit period dates that the certification or recertification covers. Physician’s signature must appear directly below the narrative, whether it is part of the form or an addendum.
  • A written attestation of a face-to-face encounter, when applicable. A hospice physician or hospice nurse practitioner must have a face-to-face encounter with each Medicare hospice patient before the beginning of the patient’s third benefit period and before each subsequent benefit period. This face-to-face encounter is part of the recertification. The physician or nurse must provide a clearly titled, written attestation of the encounter, its accompanying signature, and the date signed as a separate and distinct section of, or an addendum to, the recertification form.

See CMS’ MLN Matters No. SE1628 for more helpful guidance and a series of examples that illustrate clearly how to create a valid certification/recertification form. You may create your own format as long as it meets all the requirements. 

Find more Medicare information in TMA’s Medicare, Chronic Care Management, and MACRA resource centers.

Published March 15, 2017

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Last Updated On

March 16, 2017

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