(Medicare Benefit Policy Manual)

3.  the signature(s) of the physician(s), the date signed, and the benefit period dates that the certification or recertification covers (for more on signature requirements, see Pub. 100- 08, Medicare Program Integrity Manual, chapter 3, section 3.3.2.4).  4.  as of October 1, 2009, the physicians brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as  part of the certification and recertification forms, or as an addendum to the certification and recertification forms;    If the narrative is part of the certification or recertification form, then the narrative must be located immediately above the physicians signature.    If the narrative exists as an addendum to the certification or recertification form, in addition to the physicians signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum.   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 patients medical record or, if applicable, his or her examination of the patient.  The physician may dictate the narrative.    The narrative must reflect the patients individual clinical circumstances and cannot contain check boxes or standard language used for all patients.  The physician must synthesize the patients comprehensive medical information in order to compose this br ief clinical justification narrative.    For recertifications on or after January 1, 2011, the narrative associated with the third 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.  5.  face -to-face encounter.  For recertifications on or after January 1, 2011, a hospice physician or hospice nurse practitioner must have a face -to-face encounter with each hospice patient prior to the beginning of the patients third benefit period, and prior to each subsequent benefit period.  Failure to meet the face -to-face encounter requirements specified in this section results in a failure by the hospice to meet the patients recertification of terminal illness eligibility requirement.  The patient would cease to be eligible for the benefit.   The face to face encounter requirement is satisfied when the following criteria are met:  a. Timeframe of the encounter:  The encounter must occur prior to the recertification for the third benefit period and each subsequent benefit period.  The encounter must occur no more than 30 calendar days before the third benefit period recertification a nd each subsequent recertification.  A face- to-face encounter may occur on the first day of the benefit period and still be considered timely.  (Refer to section 20.1.5.d below for an exception to this timeframe).  b. Attestation requirements:  A hospice physician or nurse practitioner 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, and must be clearly titled.  Where a nurse practitioner or non- certifying hospice physician performed 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.   c. Practitioners who can perform the encounter:  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.  A hospice employee is one who receives a W -2 from the hospice or who volunteers for the hospice.  If the hospice is a subdivision of an agency or organization, an employee of that agency or organization assigned to the hospice is also considered a hospice employee.  Physician Assistants (PAs), clinical nurse specialists, and outside attending physicians are not authorized by section 1814(a)(7)(D)(i) of the Act to perform the face- to-face encounter for recertifi cation.   d. Timeframe exceptional circumstances for new hospice admissions in the third or later benefit period:  In cases where a hospice newly admits a patient who is in the third or later benefit period, exceptional circumstances may prevent a face- to-face encou nter prior to the start of the benefit period.  For example, 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.  Or, if CMS data systems are unavailable, the hospice may be unaware that the patient is in the third benefit period.  In such documented cases, a face to face encounter which occurs within 2 days after admission will be considered to be timely.  Additionally, for such documented exceptional cases, if the patient dies within 2 days of admission without a face to face encounter, a face to face encounter can be deemed as complete.   Recertifications that require a face -to-face encounter but which are missing the encounter are not complete.  The statute requires a complete certification or recertification in order for Medicare to cover and pay for hospice services.  Where the only reas on the patient ceases to be eligible for the Medicare hospice benefit is the hospices failure to meet the face-to-face requirement, Medicare would expect the hospice to discharge the patient from the Medicare hospice benefit, but to continue to care for t he patient at its own expense until the required encounter occurs, enabling the hospice to re -establish Medicare eligibility.  The hospice can re- admit the patient to the Medicare hospice benefit once the required encounter occurs, provided the patient continues to meet all of the eligibility requirements and the patient (or representative) files an election statement in accordance with CMS regulations.   The hospice must file written certification statements and retain them in the medical record.  Hospice staff must make an appropriate entry in the patient's medical record as soon as they receive an oral certification.   These requirements also apply to individuals who had been previously discharged during a benefit period and are being recertified for hospice care.   20.2 - Election, Revocation, and Discharge  (Rev. 209, Issued: 05- 08-15, Effective: 10 -01-14, Implementation: 05- 04-15)  20.2.1 - Hospice Election  (Rev. 246, Issued: 09- 14-18, Effective: 12 -17- 18, Implementation: 12- 17-18)  Each hospice designs and prints its election statement.  The election statement must include the following items of information:    Identification of the particular hospice that will provide care to the individual;   The individuals or representatives (as applicable) acknowledgment that the individual has been given a full understanding of hospice care, particularly the palliative rather than curative nature of treatment;    The individuals or representatives (as applicable) acknowledgment that the individual understands 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.  An individual may not designate an effective date that is retroactive;    The individuals designated attending physician (if any). Information identifying the attending physician recorded on the election statement should provide enough detail so that it is clear which physician, Nurse Practitioner (NP), or Physician Assistant ( PA) was designated as the attending physician. This information should include, but is not limited to, the attending physicians full name, office address,  NPI number, or any other detailed information to clearly identify the attending physician.     The individuals acknowledgment that the designated attending physician was the individuals or representatives choice.    The signature of the individual or representative.   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.  For Medicare payment purposes, an election for Medicare hospice care must be made on or after the date that the hospice provider is Medicare -certified.  As with any election, the hospice must fulfill all other admission requirements, such as certification or recertification, any required face- to-face encounters, or Conditions of Participation (CoP) assessments.  See also Pub. 100- 04, Medicare Claims Processing Manual, chapter 11, section 20.1.1.  An individual may change, once in each election period, the designation of the particular hospice from which he or she elects to receive hospice care.  The change of the designated hospice is not considered a revocation of the election, but is a transfer.  To change the designation of hospice programs, the individual must file, with the hospice from which he or she has received care and with the newly designated hospice, a signed statement that includes the following information:    the name of the hospice from which the individual has received care,   the name of the hospice from which they plan to receive care, and   the date the change is to be effective.   As described in Pub. 100 -04, Medicare Claims Processing Manual, chapter 11, section 20.1.1, when a hospice patient transfers to a new hospice, the receiving hospice must file a new Notice of Election; however, the benefit period dates are unaffected.  The receiving hospice must complete all assessmen ts required by the hospice conditions of participation as described in 42 CFR 418.54.  Because the benefit period does not change in a transfer situation, if the patient is in the third or later benefit period and transfers hospices, a face -to-face encount er is not required if the receiving hospice can verify that the originating hospice had the encounter. A change of ownership of a hospice is not considered a change in the patients designation of a hospice and requires no action on the patients part.   Medicare beneficiaries enrolled in managed care plans may elect hospice benefits.  Federal regulations require that the Medicare contractor assigned the hospice specialty workload maintain payment responsibility for hospice services and may pay for other claims if that Medicare contractor is the geographically assigned Medicare contractor for the managed care enrollees who elect hospice; for specifics, see regulations at  42 CFR 417, Subpart P, 417.585, Special Rules: Hospice Care (b), and 42 CFR 417.531 Hospice Care Services (b).  Institutional claims for services not related to the terminal illness would otherwise be the responsibility of another geographically assigned Medicare contractor.   Managed care enrollees who have elected hospice may revoke hospice election at any time, but claims will continue to be paid by fee -for-service Medicare contractors as if the beneficiary were a fee- for-service beneficiary until the first day of the month f ollowing the month in which hospice was revoked.  As specified above, by regulation, the duration of payment responsibility by fee -for-service Medicare contractors extends through the remainder of the month in which hospice is revoked by hospice beneficiar ies.  See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 2, Admission and Registration and Chapter 11, Processing Hospice Claims, for requirements for hospice reporting to the Medicare contractor.   20.2.1.1 - Hospice Election  Statement  (Rev. 10437, Issued: 11- 06-20, Effective: 10 -01-20, Implementation: 12- 09-20)  An individual who meets the eligibility requirements of  418.20 may file an election statement with a particular hospice. If the individual is physically or mentally incapacitated, his or her representative (as defined in  418.3) may file the election statement.   Each hospice designs and prints its election statement.  The election statement must include the following items of information:   1. Identification of the particular hospice that will provide care to the individual;  2. The individuals or representatives (as applicable) acknowledgment that the individual has been given a full understanding of hospice care, particularly the palliative rather than curative nature of treatment;   3. The individuals acknowledgement that the individual has been provided information on the hospice's coverage responsibility and that certain Medicare services are waived by the election. For hospice elections beginning on or after October 1, 2020, this would include providing the individual with information indicating that services unrelated to the terminal illness and related conditions are exceptional and unusual and the hospice should be providing virtually all care needed by the individual who has elect ed hospice;   4. 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.  An individual may not designate an effective date that is retroactive;