Documentation

80.1 - Documentation (Rev. 188, Issued: 05-01-14; Effective: 08-04-14; Implementation: 08-04-14) If the beneficiary’s physician initiates the request for the evaluation and counseling service, appropriate documentation guidelines should be followed, including the determination of the terminal illness. Since this provision is not a prerequisite of or part of the hospice benefit, certification of the terminal illness is not required. The request or referral should be in writing, and the hospice medical director or physician employee would be expected to provide a written note on the patient’s medical chart as well as maintaining a written record of this service. If the beneficiary initiates the request for the service, the hospice agency should maintain a written record of the service and communication with the beneficiary’s physician, with the beneficiary’s permission, would occur, to the extent necessary to ensure continuity of care.