Tip for Hospice Certification (CMS)

The certifying physician must provide a brief narrative explaining the clinical basis for the terminal prognosis

Tip for Hospice Certification (CMS)

Face-to-face encounters for recertification must be performed by a hospice physician or NP — the attending physician cannot perform this

Tip for Hospice Certification (CMS)

Recertification requires demonstrating continued decline and a terminal prognosis, not just re-signing a form

HospicemoderateDoctor signature required

Hospice Certification / Recertification

Hospice Certification (CMS) · CMS

Physician certification that the patient has a terminal illness with a prognosis of 6 months or less. Required at the start of each benefit period. Face-to-face encounter required before the third benefit period and each subsequent period.

Form Details

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Where to Submit This Form

📠

Fax to the hospice medical director for signature

The attending physician and hospice medical director must both certify the terminal prognosis.

📬

Mail to the hospice provider for the medical record

Filing Deadline

Initial certification: at the start of hospice. Recertification: at the beginning of each benefit period (two 90-day periods, then 60-day periods). Must include a face-to-face encounter before the third benefit period and each subsequent period.

Required Attachments

📎 Physician certification of terminal illness with 6-month prognosis
📎 Clinical documentation supporting the terminal prognosis
📎 Hospice medical director signature
📎 Attending physician signature (if the patient has an attending physician)
📎 Face-to-face encounter documentation (required for 3rd and subsequent benefit periods)

Processing Time

The certification itself is a physician order. Processing for Medicare billing purposes is handled by the hospice provider when submitting claims.

What Happens Next

The certification authorizes continued hospice benefits for the current benefit period. The hospice provider files the certification with Medicare claims. Without timely recertification, Medicare will not pay for hospice services.

Tips for This Form

✓ The certifying physician must provide a brief narrative explaining the clinical basis for the terminal prognosis
✓ Face-to-face encounters for recertification must be performed by a hospice physician or NP — the attending physician cannot perform this
✓ Recertification requires demonstrating continued decline and a terminal prognosis, not just re-signing a form
✓ Late recertifications can result in claim denials and payment recoupments

More Hospice Forms

Hospice Election Statement

Hospice Election (CMS model) · CMS / Hospice Agency

Elects the Medicare hospice benefit. Identifies the hospice and attending physician. Acknowledges waiver of curative treatment for the terminal illness. Triggers two 90-day benefit periods followed by unlimited 60-day periods.

Hospice Notice of Election (NOE)

NOE (CMS electronic) · CMS

Electronic notification to Medicare contractor that a beneficiary has elected hospice. Must be filed within 5 calendar days of the election effective date. Late filing results in provider liability for uncovered days.

Hospice Notice of Termination/Revocation (NOTR)

NOTR (CMS) · CMS

Filed when a hospice beneficiary is discharged alive or revokes the election. Must be submitted within 5 calendar days of the effective date.

Hospice Revocation Statement

Revocation Statement · Hospice Agency

Written statement revoking hospice election for a specific benefit period. Patient may re-elect hospice for remaining benefit periods. Verbal revocation is not acceptable; must be in writing.

Hospice Transfer Form

Transfer Form · Hospice Agency

Change of designated hospice provider (allowed once per election period). Not a revocation. Receiving hospice files a new NOE; benefit period dates are unaffected.

Hospice Physician Discharge Order

Discharge Order · Hospice Agency

Written physician order required before discharging a patient for any reason other than revocation, transfer, or death. Documents the clinical rationale for discharge.

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