Medicare Hospice
Benefit
Requirements for Eligibility and Coverage
Katherine Lucas, PhD
August 24, 2011
Office of the Inspector
General (OIG) Report
• Issued September 2009
• Entitled “Medicare Hospice Care for Beneficiaries
in Nursing Facilities: Compliance with Medicare
Coverage Requirements”
• Objective: to determine the extent to which hospice
claims for beneficiaries in nursing facilities in 2006
met Medicare coverage requirements.
2
Sep 2009 OIG Report
Regarding claims for hospice beneficiaries in
nursing facilities:
• 82% did not meet at least 1 Medicare coverage
requirement;
• 33% did not meet election requirements;
3
Sep 2009 OIG Report
• 63% did not meet plan of care (POC)
requirements;
• For 31% of claims, hospices provided fewer
services than in the POC;
• 4% did not meet certification requirements.
4
Sep 2009 OIG Report
The OIG made 3 recommendations:
• Educate hospices about the coverage
requirements and their importance in ensuring
quality of care;
• Provide tools and guidance to hospices to help
them meet the coverage requirements;
• Strengthen the monitoring practices regarding
hospice claims.
5
Focus
This presentation focuses on
the first two OIG recommendations,
related to education and to
providing guidance.
6
Medicare Statute
• Coverage requirements are given in the Medicare
statute, which is in the Social Security Act (the Act)
• Key hospice sections of the Act include:
 1812(d): benefits periods, election, services waived
upon election
 1814(a)(7): requirements for coverage & certification
 1814(i): for Medicare payment, services must be
reasonable
 1861(dd): definition of terminal illness, attending
physician
7
Medicare Regulations
• The Code of Federal Regulations (CFR) outlines
eligibility, coverage, and payment regulations
based on the statutory requirements in CFR Title
42, Sections 418.20 – 418.30 and
418.200 – 418.405 .
• The sections of the CFR in between §418.30 and
§418.200 are the Conditions of Participation and
are not our focus today.
8
Benefit Policy Manual
• CMS provides guidance to understand eligibility,
election, and coverage requirements in its Hospice
Benefit Policy Manual, which is available online as
Internet Only Manual (IOM) 100-02, Chapter 9.
• The manual can be accessed from the hospice
center webpage:
www.cms.gov/center/hospice.asp
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Benefit Policy Manual
• We encourage providers to refer to the Hospice
Benefit Policy Manual (BPM), as it’s an easily
accessible tool and explains our coverage
requirements. The content of this presentation
is in our BPM, and addresses the OIG’s
concerns.
• The BPM is referenced throughout these slides
as BPM followed by the section number (i.e.,
BPM §20.1)
10
Coverage Requirements
Per §418.200, “Requirements for Coverage” for
beneficiaries who meet the hospice eligibility
requirements:
1) Hospice services must be reasonable and
necessary for the palliation and management of
the terminal illness as well as related
conditions.
2) The individual must elect hospice care in
accordance with §418.24.
11
Coverage Requirements
3) A plan of care must be established and
periodically reviewed by the attending physician,
the medical director, and the interdisciplinary
group of the hospice program as set forth in
§418.56.
4) That plan of care must be established before
hospice care is provided.
12
Coverage Requirements
5) The services provided must be consistent with
the plan of care.
6) A certification that the individual is terminally
ill must be completed as set forth in §418.22.
All of these requirements must be met for
Medicare to cover and pay for hospice services.
13
Eligibility for
Medicare’s Hospice
Benefit:
42 CFR §418.20
14
Eligibility
• The beneficiary must have Medicare Part A .
• The beneficiary must be certified by a hospice
physician and the attending physician (if any) as
being terminally ill, with a life expectancy of 6
months or less if the illness runs its normal course.
• The beneficiary is considered terminally ill if
he/she has a medical prognosis of 6 months or
less.
• Source: §418.20 and BPM §10
15
Benefit Periods:
42 CFR §418.21
16
Benefit Periods
• Hospice care is organized into benefit periods:
 The periods consist of two 90-day periods
and an unlimited number of 60-day periods.
 The periods of care are available in the
order listed and may be elected separately at
different times.
• Source: §418.21 and BPM §10
17
Certification
Requirements:
42 CFR §418.22
18
Certification of
Terminal Illness (CTI)
• The hospice must obtain written certification of
terminal illness for each benefit period, even if a
single election continues in effect for an
unlimited number of periods.
• Source: §418.22(a)(1) & BPM 20.1
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Timeframe for Completion
• If the hospice cannot obtain the written
certification within 2 calendar days after a period
begins, it must obtain an oral certification within
2 calendar days and the written certification
before it submits a claim for payment.
• Source: §418.22(a)(2)&(3) & BPM §20.1
20
Timeframe for Completion
• Certifications and recertifications can be completed no
more than 15 days prior to the start of the benefit
period.
– A certification or recertification is made up of several
components, one of which is the face-to-face
encounter. The face-to-face encounter must be
completed prior to, but no more than 30 calendar
days prior to, the start of the benefit period.
•
Source: §418.22(a)(3)&(4) & BPM §20.1
21
CTI Content
• Certification will be based on the physician's or
medical director's clinical judgment regarding the
normal course of the individual's illness.
 Predicting of life expectancy is not always exact.
The fact that a beneficiary lives longer than
expected in itself is not cause to terminate
benefits.
• Source: §418.22(b) & BPM §10
22
CTI Content
• The certification must conform to the
following requirements:
1) It must specify that the individual's prognosis
is for a life expectancy of 6 months or less if
the terminal illness runs its normal course.
•
Source: §418.22(b)(1) & BPM §20.1
23
CTI Content
2) Clinical information and other documentation
that support the medical prognosis must
accompany the certification and must be filed in
the medical record with the written
certification. Initially, the clinical information
may be provided verbally, and must be
documented in the medical record and included
as part of the hospice's eligibility assessment.
•
Source: §418.22(b)(2) & BPM §20.1
24
CTI Content
3)The physician must include a brief narrative
explanation of the clinical findings that supports a
life expectancy of 6 months or less as part of the
certification & recertification forms, or as an
addendum to the certification & recertification forms.
 If the narrative is part of the certification or
recertification form, then the narrative must be located
immediately prior to the physician's signature.
•
Source: §418.22(b)(3) & BPM §20.1
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CTI Content
 If the narrative exists as an addendum to the
certification or recertification form, in addition to
the physician's signature on the certification or
recertification form, the physician must also sign
immediately following the narrative in the
addendum.
 Source: §418.22(b)(3) & BPM §20.1
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CTI Content
 The narrative shall include a statement directly
above the physician signature attesting that by
signing, the physician confirms that he/she
composed the narrative based on his/her
review of the patient's medical record or, if
applicable, his/her examination of the patient.
 Source: §418.22(b)(3) & BPM §20.1
27
CTI Content
 The narrative must reflect the patient's individual
clinical circumstances and cannot contain check
boxes or standard language used for all patients.
 The narrative associated with the 3rd benefit 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 6 months or less.
 Source: §418.22(b)(3) & BPM §20.1
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CTI Content
• A hospice physician or NP who performs the encounter
must attest in writing that he or she had a face-to-face
encounter with the patient, including the date of the
encounter;
• The attestation, its accompanying signature, and the date
signed, must be a separate and distinct section of, or an
addendum to, the recertification form, & must be clearly
titled.
• Source: §418.22(b)(4), BPM §20.1, Hospice face-to-face
guidance Powerpoint, Hospice Center webpage
29
CTI Content
• 4) The written certifications and recertifications
must include the signature(s) of the physician(s),
the date signed, and the benefit period dates that
the certification or recertification covers.
 Source: §418.22(b)(5) & BPM §20.1
30
Sources of Certifications
• For the initial 90-day period, the hospice must obtain
written certification statements (and oral certification
statements if applicable) from—
 The medical director of the hospice or the physician
member of the hospice interdisciplinary group (IDG);
and
 The individual's attending physician, if any.
• For subsequent periods, the only requirement is
certification by the hospice medical director or physician
member of the IDG.
• Source: §418.22(c) & BPM §20.1
31
Sources of Certification
• “Attending physician” is defined as a doctor of medicine
or osteopathy, or nurse practitioner, who is identified by
the individual, at the time he or she elects to receive
hospice care, as having the most significant role in the
determination and delivery of the individual's medical
care.
• The statute prohibits nurse practitioners from certifying or
recertifying hospice patients.
• Source: §418.3, §418.22(c)(1)(ii) & BPM §10, §20.1, §40.1.3.2
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CTI Records
Hospice staff must—
(1) Make an appropriate entry in the patient's
medical record as soon as they receive an oral
certification; and
(2) File written certifications in the medical
record.
• Source: §418.22(d) & BPM §20.1
33
Signature Requirements
• Valid certifications and recertifications may be
signed electronically or by hand. Stamped
signatures are not acceptable.
• Source: Medicare Program Integrity Manual, (IOM 10009, Chapter 3), section 3.3.2.4
34
Face-to-Face Encounter
• The hospice face-to-face encounter was
required in the Affordable Care Act, which
became effective January 1, 2011.
• The face-to-face encounter requirements are
included in the regulations related to the
certification of terminal illness, and reflect the
language in the statute.
35
Face-to-Face Encounter
• CMS requires that prior to the beginning of the patient’s
3rd benefit period, and prior to each subsequent benefit
period, a hospice physician or hospice nurse practitioner
(NP) must have a face-to-face encounter with the
individual to determine continued eligibility of the
individual for hospice care and attest that such a visit took
place.
• The provision is effective for 3rd benefit periods or later
periods which occur on or after January 1, 2011.
• Source: §418.22(a)(4), BPM 20.1, Hospice face-to-face guidance
Powerpoint, Hospice Center webpage
36
Timing of the Encounter
• The face-to-face encounter must occur prior to,
but no more than 30 calendar days prior to, the
3rd benefit period recertification, and prior to,
but no more than 30 calendar days prior to,
every subsequent recertification thereafter.
• Source: §418.22(a)(4), BPM 20.1, Hospice face-to-face
guidance Powerpoint, Hospice Center webpage
37
Who Can Perform
the Encounters
Only a hospice physician or a hospice nurse
practitioner can perform the encounter.
A hospice physician is a physician who is employed
by the hospice or working under contract with the
hospice.
A hospice nurse practitioner must be employed by
the hospice.
• Source: §418.22(a)(4) & BPM §20.1
38
“Employee” Definition
A hospice “employee” means a person who:
(1) Works for the hospice and for whom the
hospice is required to issue a W–2 form on his
or her behalf;
(2) if the hospice is a subdivision of an agency
or organization, an employee of the agency or
organization who is assigned to the hospice; or
(3) is a volunteer under the jurisdiction of the
hospice.
• Source: §418.3 and BPM §20.1
39
CTI Content: Face-toFace Attestation
The physician or nurse practitioner (NP) who
performs the face-to-face encounter with the
patient must attest in writing that he or she had
a face-to-face encounter with the patient,
including the date of that visit.
• Source: §418.22(b)(4) & BPM §20.1
40
Attestation
• When a physician other than the certifying physician
or an NP performs the encounter, the attestation must
state that the clinical findings of that visit were
provided to the certifying physician, for use in
determining whether the patient continues to have a
life expectancy of 6 months or less, should the illness
run its normal course
• Source: §418.22(b)(4), BPM §20.1, Hospice face-to-face
guidance Powerpoint, Hospice Center webpage
41
Attestation
• The recertifying physician’s attestation regarding the
face-to-face encounter can be included on the
recertification itself or an addendum to the
recertification.
• If the attestation is included on the recertification, it
must be located above the physician’s signature. One
physician signature may suffice for the attestation,
narrative and recertification.
• Source: Hospice face-to-face guidance Powerpoint, Hospice
Center webpage
42
Attestation
• Where both the encounter attestation and
narrative are included as an addendum to the
recertification, one physician signature can
suffice for both the narrative and attestation.
Both the narrative and the attestation must be
located above the physician signature.
• Source: Hospice face-to-face guidance Powerpoint,
Hospice Center webpage
43
Attestation
• The physician or NP who performed the encounter must
sign the attestation. If a practitioner other than the
recertifying physician (such as an NP) performed the
encounter, a separate encounter attestation signature is
required. The encounter attestation can be on the same
page as the recertification and narrative, but must be a
separate section above the signature of the physician or
NP who performed the encounter. The attestation can
also be a signed addendum to the certification.
• Source: Hospice face-to-face guidance Powerpoint, Hospice
Center webpage
44
Face to Face Encounter
• Only the recertifying physician can sign the
certification and physician narrative.
• Source: Hospice face-to-face guidance Powerpoint,
Hospice Center webpage
45
Timing Exceptions for Face-to-Face
Encounters for New Admissions
Where a hospice newly admits a patient who is in
the 3rd or later benefit period, exceptional
circumstances may prevent a timely face-to-face
encounter prior to the start of the benefit period. In
such documented cases, a face-to-face encounter
which occurs within 2 days after admission will be
considered timely. Three examples follow:
•
Source: BPM §20.1
46
Timing Exceptions (cont.)
1) if the patient is an emergency weekend admission,
it may be impossible for a hospice physician or NP
to see the patient until the following Monday;
2) if CMS data systems are unavailable, the hospice
may be unaware that the patient is in the third
benefit period;
3) where a patient dies within 2 days of admission
without a face to face encounter, a face to face
encounter is deemed to have occurred.
• Source: BPM §20.1
47
Face-to-Face Encounters
• If the required face-to-face encounter is not
timely, the hospice would be unable to recertify
the patient as being terminally ill, and the
patient would cease to be eligible for the
Medicare hospice benefit.
• In such instances, the hospice must discharge
the patient from the Medicare hospice benefit
because he or she is not considered terminally ill
for Medicare purposes.
• Source: 418.20, Q&A 10535
48
Face-to-Face Encounters
• Where the only reason the patient ceases to be
eligible for the Medicare hospice benefit is the
hospice’s failure to meet the face-to-face
requirement, we would expect the hospice to
continue to care for the patient until
the required encounter occurs, enabling the
hospice to re-establish Medicare eligibility.
49
Face-to-Face Encounters
• Occurrence span code 77 does not apply to
situations when the face-to-face encounter has
not occurred timely.
• While a face-to-face encounter must occur
timely, the face-to-face attestation may be
completed after the benefit period begins, but
prior to billing.
• Source: Q&As 10536 & 10537
50
Face-to-Face Encounters
& Billing
• If a physician provides a medically reasonable
and necessary physician service to the patient
during the visit, that portion of the visit is billable.
• Hospices cannot bill for physician services
provided by an NP unless the NP is the attending
physician.
• Source: Hospice face-to-face guidance Powerpoint,
Hospice Center webpage
51
Electing Hospice:
42 CFR §418.24
52
Electing Hospice
Filing an election statement. An individual who
meets the eligibility requirements in §418.20
may file an election statement with a particular
hospice. If the individual is physically or
mentally incapacitated, his or her representative
may file the election statement.
• Source: §418.24(a) & BPM §10
53
Electing Hospice
“Representative” means an individual who has the
authority under State law (whether by statute or
pursuant to an appointment by the courts of the
State) to authorize or terminate medical care or
to elect or revoke the election of hospice care on
behalf of a terminally ill patient who is mentally
or physically incapacitated. This may include a
legal guardian.
• Source: §418.3
54
Electing Hospice
The election statement must include the following:
• Identification of the particular hospice that will
provide care to the individual.
• The individual's or representative's
acknowledgement that he or she has been given a
full understanding of the palliative rather than
curative nature of hospice care, as it relates to the
individual's terminal illness.
• Source: §418.24(b) & BPM §20.2
55
Electing Hospice
• Acknowledgement that certain Medicare services
are waived by the election.
• The effective date of the election, which may be
the first day of hospice care or a later date, but
may be no earlier than the date of the election
statement.
• The signature of the individual or representative.
• Source: §418.24(b) & BPM §20.2
56
Electing Hospice
Waiver of other Medicare benefits. For the duration
of an election of hospice care, an individual waives
all rights to Medicare payments for the following
services:
• Hospice care provided by a hospice other than the
hospice designated by the individual (unless
provided under arrangements made by the
designated hospice).
• Source: §418.24(d) & BPM §10
57
Electing Hospice
• Any Medicare services that are related to the
treatment of the terminal condition for which
hospice care was elected or a related condition or
that are equivalent to hospice care except for
services—
 Provided by the designated hospice:
 Provided by another hospice under
arrangements made by the designated hospice;
• Source: §418.24(d) & BPM §10
58
Electing Hospice
and
 Provided by the individual's attending
physician, who may be a nurse practitioner
(NP), if that physician or NP is not an
employee of the designated hospice or
receiving compensation from the hospice for
those services.
• Source: §418.24(d) & BPM §10
59
Electing Hospice
Duration of election: An election to receive
hospice care will be considered to continue
through the initial election period and through the
subsequent election periods without a break in care
as long as the individual—
(1) Remains in the care of a hospice;
(2) Does not revoke the election; and
(3) Is not discharged from the hospice.
• Source: §418.24(c) & BPM §10, 20.2
60
Electing Hospice
Re-election of hospice benefits. If an election has
been revoked by the patient, the individual (or his
or her representative if the individual is mentally
or physically incapacitated) may at any time file
an election for any other election period that is still
available to the individual.
• Source: §418.24(e) & BPM §20.2
61
Electing Hospice
Once the initial election is processed, the Common
Working File maintains the beneficiary in hospice
status until death or until an election termination is
received.
Source: BPM §10
62
Electing Hospice
Medicare services for a condition completely
unrelated to the terminal condition for which
hospice was elected remain available to the
patient if he or she is eligible for such care.
For example, if a hospice patient with COPD
should be injured in a car accident, those injuries
would be covered by fee-for-service Medicare.
•
Source: BPM §10
63
For More Information:
• The Code of Federal Regulations (CFR), Title
42, Part 418 is available online as an e-CFR at:
www.gpoaccess.gov/cfr/index.html
• The Hospice Benefit Policy Manual, Q&As
and Face-to-face Guidance Powerpoint are
available on the hospice center webpage at:
www.cms.gov/center/hospice.asp
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For More Information:
• Questions? Email them to:
PCGOUTREACHCALLS.DAYTWO@CMS.HHS.GOV
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