Current through Reg. 49, No. 52; December 27, 2024
(a)
Written certification.
(1) For the initial
election period, a hospice must obtain a signed and dated Physician
Certification of Terminal Illness Form that meets the requirements of this
section before the hospice submits an initial request for payment, but no more
than 15 days before the election period begins.
(2) For an election period after the initial
election period, a hospice must obtain a signed and dated Physician
Certification of Terminal Illness Form that meets the requirements of this
section before the previous period expires, but no more than 15 days before the
next election period begins.
(3)
The hospice must submit the Physician Certification of Terminal Illness Form to
the TMHP Long Term Care Online Portal.
(b) Oral certification. If a hospice does not
obtain the written certification required by subsection (a)(1) of this section
within two days after an initial election period begins, the hospice must
obtain an oral certification that meets the requirements of this section no
later than two days after the initial election period begins. The hospice must
obtain a written certification before it submits a claim for payment. An
election period is described in § 266.201 of this subchapter (relating to
Duration of Hospice Care Coverage: Election Periods).
(c) Content of certification. An oral or
written certification must:
(1) specify that
an individual's prognosis is for a life expectancy of six months or less if the
terminal illness runs its normal course;
(2) include a physician narrative that states
individual-specific clinical course, exam findings, and laboratory and
diagnostic testing results that support the physician's judgement that the
individual is terminally ill; and
(3) include clinical information that
supports the medical prognosis, which may be provided orally for an oral
certification and must be provided with accompanying documentation for a
written certification.
(d) Additional requirement for election
period after the subsequent 90-day election period. To determine an
individual's continued eligibility for hospice care for an election period
after the subsequent 90-day election period, a hospice physician or hospice
APRN must perform a face-to-face assessment of the individual.
(1) The hospice must ensure a face-to-face
assessment is performed before each subsequent election period begins, but no
more than 30 days before the subsequent election period begins.
(2) For an individual who is dually eligible
for Medicare and Medicaid, a Medicare face-to-face encounter satisfies the
requirement for a face-to-face assessment.
(e) Sources of certification. The hospice
must obtain the certification required by subsection (a) or (b) of this section
from:
(1) for the initial election period:
(A) the medical director of the hospice or a
physician who is a member of the hospice IDT; and
(B) the individual's attending physician, if
the individual has an attending physician; and
(2) for an election period after the initial
election period, a physician described in paragraph (1)(A) of this
subsection.
(f)
Documentation.
(1) After the hospice receives
a certification:
(A) for an oral
certification, the hospice physician or RN must make an entry in the
individuals' hospice record that includes the name of the physician who made
the oral certification, the clinical information that supports the prognosis,
the date the hospice received the certification, the signature of the staff
person who makes the entry, and the date of the entry; and
(B) for a written certification, the hospice
staff must file the written certification and supporting documentation in the
individual's hospice record.
(2) For an election period after the
subsequent 90-day election period, the hospice record must include clearly
labeled documentation of the face-to-face assessment.
