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.
42 C.F.R. Part 418;
Miss. Code Ann. §
43-13-121.
