Hospice Compliance Glossary

The primary federal regulation governing the Medicare hospice benefit. Divided into Subpart B (conditions of payment: eligibility, election, certification), Subpart C (conditions of participation - patient care), and Subpart D (conditions of participation - administration).

A written list of conditions, items, services, and drugs the hospice has determined are unrelated to the terminal illness and related conditions. Required to be titled 'Patient Notification of Hospice Non-Covered Items, Services, and Drugs.' Effective October 1, 2020.

The physician (MD, DO), nurse practitioner (NP), or physician assistant (PA) identified by the patient or representative at the time of election as having primary responsibility for the patient's medical care. The patient's choice, not the hospice's assignment.

Beneficiary and Family Centered Care Quality Improvement Organization. Medicare beneficiaries on hospice have the right to contact the BFCC-QIO for immediate advocacy regarding concerns about quality of care or premature discharge. Contact information must be provided in the election statement (post-2020).

The structure of hospice coverage under Medicare: two initial 90-day periods followed by unlimited 60-day periods. Each period requires a new certification. The Face-to-Face encounter requirement activates starting with the 3rd benefit period.

Medicare Benefit Policy Manual, Publication 100-02. Chapter 9 operationalizes hospice coverage requirements including clinical eligibility, certification content, narrative requirements, and oral certification exceptions.

A formal document signed by a physician certifying that a patient is terminally ill with a prognosis of 6 months or less if the illness runs its normal course. Must include a patient-specific narrative, supporting clinical information, signature, signature date, and benefit period dates.

Medicare Claims Processing Manual, Publication 100-04. Chapter 11 governs hospice billing mechanics including NOE submission, timely filing rules, provider-liable day calculations, and exception documentation for late NOEs.

Requirements hospices must meet to participate in Medicare. Survey-enforced. Deficiencies can result in citations, enforcement actions, or termination. Distinguished from conditions of payment, which affect claim reimbursement directly.

A process used when a patient changes their identified attending physician after election. Governed by hospice policy and election statement update requirements. Not the same as the hospice physician or medical director.

One of the 7 required comprehensive assessment domains under 42 CFR 418.54(b). The hospice must assess the patient's current drug regimen for therapeutic duplication, contraindications, and appropriateness for comfort-focused palliative care.

The formal act by which a Medicare beneficiary (or representative) chooses to receive the hospice benefit from a specific hospice. Documented through the election statement. The effective date starts all compliance clocks.

The legal enrollment document through which a beneficiary formally elects the hospice benefit. Must contain all required elements including hospice identification, attending physician choice, palliative care acknowledgement, waiver of curative services, effective date, and beneficiary signature.

A required in-person (or telehealth, when authorized) clinical encounter that must occur within 30 calendar days before the start of the 3rd and each subsequent benefit period. May only be conducted by the hospice physician or hospice nurse practitioner. The attestation must contain the encounter date, practitioner signature, and signature date.

A term used in this training resource to describe compliance requirements that must occur before proceeding - not optional steps. The five hard stops in hospice admission are: (1) eligibility/certification, (2) election, (3) admission recommendation, (4) NOE filing, and (5) patient rights + assessment timelines.

The core team required by 42 CFR 418.56 to be responsible for hospice care delivery. Must include at minimum: a physician, registered nurse, social worker, and pastoral/spiritual care counselor. The IDG collaborates to develop, implement, and review the plan of care.

An assessment completed by a registered nurse within 48 hours of the hospice election effective date, at the location where services will be delivered. Must identify immediate needs - not a social visit. Patient rights must be delivered before clinical tasks begin at this visit.

The citation format used in the State Operations Manual (SOM) Appendix M for hospice survey deficiencies. For example, L522 corresponds to 42 CFR 418.52(a) - patient rights. Surveyors cite specific L-tags when documenting deficiencies.

Regional contractors that process Medicare claims and receive hospice NOEs. For hospice, the relevant MAC is the Home Health and Hospice MAC (HHH MAC). NOE acceptance by the MAC - not just submission - must occur within 5 calendar days of election.

A physician employed or contracted by the hospice who is responsible for the medical component of the hospice's patient care program. Responsible for admission recommendations, certification/recertification review, and oversight of the IDG's clinical decision-making.

Medicare coverage provided through private health plans contracted with CMS. Patients enrolled in MA may have different hospice election, NOE, and coverage rules from traditional Medicare. Confirmation of plan-specific rules is required before applying traditional Medicare timelines.

The formal notice filed by the hospice with the Medicare contractor (MAC) confirming a beneficiary's election of the hospice benefit. Must be accepted by the MAC within 5 calendar days of the election effective date. Late NOE creates provider-liable days.

A notice given to Medicare beneficiaries when coverage for a Medicare-covered service is ending. Required when transitioning patients from a covered skilled nursing facility or home health benefit to avoid beneficiary liability claims.

A licensed advanced practice registered nurse. May serve as a patient's attending physician if identified by the patient at election. May also conduct the Face-to-Face encounter for 3rd+ benefit period recertification when employed by the hospice.

If written certification cannot be obtained at the start of a benefit period, the hospice must obtain oral certification within 2 calendar days and then secure the written certification before submitting a claim.

Conditions of Participation that most directly impact patient care and safety. Under QSO-23-08, these receive enhanced scrutiny during hospice surveys. Phase I includes: patient rights (418.52), initial assessment (418.54(a)), comprehensive assessment (418.54(b)), and IDG/POC (418.56).

A written, individualized care plan developed through IDG collaboration before hospice care is provided. Must address the patient's specific diagnoses, goals, and care interventions. Must be reviewed and updated at least every 15 calendar days.

See 'Plan of Care (POC)' above.

A functional assessment tool commonly used in hospice to measure a patient's functional status as a proxy for prognosis. Not required by regulation but widely used to document the clinical trajectory in certification narratives.

The foundational eligibility requirement for the Medicare hospice benefit: a physician must certify that the patient has a life expectancy of 6 months or less if the illness runs its normal course. This is a prognostic estimate - patients are not discharged simply for surviving longer.

Days for which Medicare will not pay and the hospice also cannot bill the beneficiary. Arises when the NOE is not accepted within 5 calendar days. The hospice absorbs the financial loss for services provided during the gap period.

A CMS Survey & Operations Group memo (January 6, 2023) that overhauled hospice survey operations. Directed surveyors to use a quality-of-care investigative orientation, enhanced Phase I CoP scrutiny, and authorized complaint surveys even for recently accredited hospices.

A required program under 42 CFR 418.58 that requires hospices to implement data-driven quality monitoring, identify performance gaps, and implement improvement activities. Surveyors examine QAPI programs under QSO-23-08's quality-of-care framework.

The process by which a physician re-certifies a patient as terminally ill for a subsequent benefit period. Requires the same narrative and signature requirements as initial certification. F2F encounter required for 3rd and subsequent periods.

The person authorized to act on behalf of a hospice patient who is mentally or physically incapacitated. May file the election statement, receive patient rights, and sign the addendum. Representative authority must be documented in the clinical record.

The only discipline authorized to conduct the initial assessment under 42 CFR 418.54(a). The RN must be the one to complete the 48-hour initial assessment - other IDG members may accompany but do not satisfy the requirement.

Medicare State Operations Manual, Publication 100-07. Appendix M contains the full hospice survey interpretive guidelines with L-tag to CoP mapping. The SOM is the operational guide surveyors use during on-site surveys.

Defined in 42 CFR 418.3 as: the individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course. This is the statutory eligibility standard for the Medicare hospice benefit.

The use of real-time audio-visual technology to conduct the Face-to-Face encounter. Was authorized as a COVID-era temporary extension. Extended by statute through January 30, 2026. Current authority must be verified against CMS Hospice Center guidance before use.

By electing the hospice benefit, a Medicare beneficiary waives the right to Medicare payment for curative treatment of the terminal illness and related conditions. The waiver is acknowledged in the election statement. Non-covered services related to the terminal illness may appear in the addendum.