Certification and Recertification of Terminal Illness

Certification and Recertification of Terminal Illness A. Only a Medicaid enrolled medical doctor or doctor of osteopathy can certify or recertify a terminal illness. B. A beneficiary who reaches a point of stability and no longer meets the definition of terminally ill must not be recertified and must return to Medicaid benefits, if eligible. C. The physician(s) signing the written certification/recertification statement can be held liable for causing false claims to be submitted. D. Certifications/recertifications of terminal illness are based on the clinical judgment of the certifying physician(s) regarding the normal course of the beneficiary's terminal illness and must conform to the following requirements: 1. The certification/recertification must specify that the beneficiary's prognosis is for a life expectancy of six (6) months or less if the terminal illness runs its normal course. 2. Clinical information and other documentation that support the medical prognosis of six (6) months or less must accompany the certification including, but not limited to, a) Terminal diagnosis and related diagnoses, b) Specific clinical findings, prognostic indicators, functional ability scales, symptom management scales, and other pertinent medical documentation, c) Coordinating national or local coverage determinations, if any, d) Laboratory reports, e) Radiology reports, and/or f) Pathology reports. 3. The certifying physician must complete a brief narrative explanation of the clinical findings that supports a life expectancy of six (6) months or less on the certification/recertification form, or as an attachment to the certification/recertification form. a) If the narrative exists as an attachment to the certification/recertification form, in addition to the physician's signature on the certification/recertification form, the physician must also sign immediately following the narrative in the addendum. b) The narrative must include a statement directly above the physician signature attesting that by signing, the narrative is based on his/her review of the beneficiary's medical record or, if applicable, his/her examination of the beneficiary. c) The narrative must reflect the beneficiary's individual clinical circumstance and cannot contain check boxes or standard language used for all beneficiaries. d) The narrative associated with the third election period recertification and every subsequent recertification must include an explanation of why the clinical findings of the face-to-face encounter support a life expectancy of six (6) months or less. 4. The physician or nurse practitioner who performs the face-to-face encounter with the beneficiary must attest in writing that he or she had a face-to-face encounter with the beneficiary, including the date of the visit. The attestation of the nurse practitioner or a non-certifying hospice physician must state the clinical findings of that visit were provided to the certifying physician for use in determining continued eligibility for hospice care. 5. All certifications/recertifications of terminal illness must be signed, dated, and must include the election period dates to which the certification or recertification applies. E. The hospice must obtain written certification of terminal illness for each election period, even if a single election continues in effect. 1. For the initial ninety (90) day election period, the hospice must obtain written certification statements from: a) The medical director of the hospice or the physician member of the hospice interdisciplinary group, and b) The beneficiary's attending physician, if the beneficiary has an attending physician. 2. For subsequent election periods, the only requirement is recertification by the hospice medical director or physician member of the hospice interdisciplinary group. F. The hospice provider must obtain written certification of terminal illness within two (2) calendar days, after the initiation of hospice care. 1. If the hospice cannot obtain the written certification of terminal illness within two (2) calendar days, after the initiation of hospice care, the hospice must obtain a verbal certification of terminal illness within two (2) calendar days. The hospice must obtain the written certification/recertification of terminal illness no later than eight (8) days after care is initiated and before submitting a claim for payment. 2. For recertifications, the hospice must obtain, no later than two (2) calendar days after the beginning of that period, a written certification statement prepared by the medical director of the hospice or the physician member of the hospice’s interdisciplinary group. G. Certifications/recertifications of terminal illness cannot be completed more than fifteen (15) calendar days prior to the effective date of the election period. H. As of January 1, 2011, a hospice physician or hospice nurse practitioner must have a face-to- face encounter to gather clinical findings to determine continued eligibility for hospice care services for each hospice beneficiary whose total stay across all hospices is anticipated to reach the third benefit period. The face-to-face encounter must: 1. Occur no more than thirty (30) calendar days prior to the third election period recertification, and 2. Occur every election period recertification, thereafter.