Hospice CoP Training - Spartan Coaching

Eligibility Baseline

A beneficiary must be Part A entitled and certified as terminally ill, defined in 42 CFR 418.3 as a medical prognosis of life expectancy of 6 months or less if the illness runs its normal course.

The hospice may admit a patient only on the recommendation of the hospice medical director (or physician designee) or the physician member of the hospice IDG, with consultation or input from the patient's attending physician if the patient has one. 42 CFR 418.25

What Must Be Considered at Admission

The admission-to-hospice regulation requires consideration of at least: (1) primary diagnosis, (2) other health conditions (related or unrelated), and (3) current clinically relevant information supporting the diagnoses.

Benefit Period Structure

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

Initial period only requires dual certification. If the patient has an attending physician, that physician must also certify in the first benefit period. Subsequent periods require only one physician (hospice role).

Certification Timing Rules

General rule: Written certification must exist before claim submission.

Oral certification exception: If the hospice cannot obtain written certification within 2 calendar days after a period begins, it must obtain an oral certification within 2 calendar days and then obtain the written certification before submitting the claim. 42 CFR 418.22(a)(3)(i)

Early completion boundary: Certifications may be completed no more than 15 calendar days before the effective date of election. Recertifications may be completed no more than 15 calendar days before the start of the subsequent benefit period. 42 CFR 418.22(a)(3)(ii)

Timing Failure = Claim Denial

Certification that does not meet timing rules is not merely a survey deficiency. It directly affects claim payment. A missing or late certification creates a billing gap that may result in denial for the entire benefit period until a compliant certification is obtained.

Required Certification Content

Every certification and recertification must contain all of the following 42 CFR 418.22(b):

Required Element	What It Means Operationally	Common Failure
6-month prognosis statement	Must state prognosis of 6 months or less if illness runs its normal course	Generic boilerplate language without patient-specific support
Patient-specific narrative	Certifying physician must provide clinical findings that support the prognosis. No checkbox templates.	Copied/templated narrative that does not reflect the individual patient's decline trajectory
Supporting clinical information	Must accompany certification and be filed in the medical record; may initially be verbal but must be documented	Narrative submitted without corresponding clinical documentation in the record
Physician signature and date	All certifications must be signed and dated by the certifying physician(s)	Unsigned certifications; missing signature date (FY 2026 rule restored this requirement)
Benefit period dates	Certification must include the specific benefit period dates to which it applies	Missing start/end dates; dates that do not align with election timeline

No Templated Narratives

CMS explicitly prohibits certification narratives that are templated “checkbox” language used for all patients. The narrative must reflect the individual patient's clinical trajectory, functional decline, and prognosis-supporting findings. This is one of the highest-frequency deficiency patterns in medical review.

Face-to-Face (F2F) Encounter Requirements

For the 3rd and each subsequent benefit period, a face-to-face encounter is required as a condition of recertification. 42 CFR 418.22(a)(4)

Who may conduct the F2F: Only the hospice physician or the hospice nurse practitioner (NP). Not the attending physician, not a physician outside the hospice organization.

Timing window: The encounter must occur within the 30 calendar days prior to the start of the benefit period being recertified.

Attestation must include: (1) the date of the encounter, (2) the practitioner's signature, and (3) the signature date. The FY 2026 Hospice Final Rule restored the signature-date requirement. Missing signature dates on attestations is a documented high-frequency failure.

Telehealth authority: Telehealth for the F2F encounter was a time-limited COVID-era extension. It was extended through January 30, 2026 by statute and CMS guidance, but its status should always be verified against current CMS Hospice Center guidance before use.

F2F Escalation Triggers

Escalate immediately to the medical director if: the wrong practitioner conducted the encounter; the encounter occurred outside the 30-day window; telehealth was used outside permitted authority; or the attestation is missing the signature date or visit date.

Key Regulatory Citations

Citation	Covers
42 CFR 418.20	Medicare hospice eligibility baseline: Part A, terminal illness definition
42 CFR 418.3	Definition of "terminally ill": 6-month prognosis standard
42 CFR 418.21	Benefit period structure: 90/90/60-day periods
42 CFR 418.22	Certification and recertification: complete requirements
42 CFR 418.22(a)(3)	Timing rules: written and oral certification exception
42 CFR 418.22(a)(4)	Face-to-face encounter requirement for 3rd+ periods
42 CFR 418.22(b)(3)	Patient-specific narrative requirement
42 CFR 418.25	Admission decision: medical director recommendation
MBPM Pub. 100-02, Ch. 9, §20.1	Operationalizes certification requirements; clinical record requirements

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Eligibility & Certification

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