Certification of Terminal Illness Checklist

42 CFR 418.22 · MBPM Pub. 100-02, Ch. 9, §20.1 · FY 2026 Hospice Final Rule

Spartan Coaching

Educational Use Only

Patient Name:

Date of Birth:

Primary Terminal Diagnosis:

Benefit Period Number:

Period Start Date:

Period End Date:

Step 1 - Confirm Correct Signatory for This Benefit Period

Benefit Period	Duration	Required Signatories	F2F Required?
1st period	90 days	Hospice MD/designee/IDG physician AND attending physician (if patient has one)	No
2nd period	90 days	Hospice MD/designee/IDG physician only	No
3rd period	60 days	Hospice MD/designee/IDG physician only	Yes - within 30 days before period start
Each subsequent 60-day	60 days	Hospice MD/designee/IDG physician only	Yes - within 30 days before period start

Certifying physician(s) for this period:

Step 2 - Required Certification Content (42 CFR 418.22(b))

No templated narratives. CMS requires a patient-specific narrative. Copied boilerplate is a high-frequency denial trigger in medical review and a survey deficiency trigger.

6-month prognosis statement: life expectancy of 6 months or less if illness runs its normal courseMust reference the patient's individual clinical trajectory, not generic language 418.22(b)(1)

Patient-specific clinical narrative supporting the prognosisInclude functional decline trajectory, relevant clinical findings, disease-specific indicators (e.g., PPS score, weight loss trend, lab trends, FAST staging) 418.22(b)(3)

Supporting clinical information exists in the medical record (chart documentation supports narrative)Surveyors cross-reference the narrative against actual chart content 418.22(b)(2)

Certification covers this specific benefit period only (not open-ended)Benefit period start and end dates present 418.22(a)(3)(ii)

Certification completed within the required timing windowWritten cert: before claim submission. Oral exception: within 2 days of period start if written not available 418.22(a)(3)

Step 3 - Certification Narrative (Write Directly Here or Attach)

Include: primary diagnosis and relevant comorbidities, current functional status (PPS/FAST/other), symptom burden and trajectory, relevant clinical findings (weight, labs, hospitalizations), and the specific basis for a prognosis of 6 months or less.

PPS Score (if used):FAST Stage (if applicable):

Step 4 - Face-to-Face Attestation (3rd Period and Beyond Only)

Only required beginning with the 3rd benefit period. The F2F encounter must be conducted by a hospice physician or hospice NP - NOT the attending physician. 42 CFR 418.22(a)(4)

F2F encounter conducted by hospice physician or hospice NP (not the attending)418.22(a)(4)

Encounter occurred within 30 calendar days before the benefit period being recertified418.22(a)(4)

F2F encounter date documented in attestationFY 2026 rule requires encounter date, practitioner signature, AND signature date 418.22(b)(4)

Practitioner signature on attestation418.22(b)(4)

Signature date on attestation (FY 2026 requirement - date of attestation signature)FY 2026 Final Rule; 418.22(b)(4)

F2F narrative completed: patient's clinical status and findings that support recertificationNot a checkbox; must reflect the actual encounter findings SOM Appendix M

Telehealth use (if applicable): verify current CMS authority - not permanently authorizedCheck CMS Hospice Center for current guidance

F2F encounter date:

Attestation signature date:

Sign-Off

Certifying Physician:

Credentials:

Signature:

Signature Date:

Attending Physician (1st period only):

Credentials:

Signature:

Signature Date:

Educational Use Only. Not legal advice. Verify against current primary sources and your organization's policies before use.