Hospice Services

Affected Providers

Medicare certified hospital-based and non-hospital-based hospice programs.

Background

We define hospice services as all services with a provider type of hospice, including hospital-based hospice and non-hospital-based hospice.

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for non-hospital-based hospice services is 6.8%, with a projected improper payment amount of $1.6 billion. The improper payment rate for hospital-based hospice services is 10.8%, with a projected improper payment amount of $190.6 million.

Denial Reasons

2024 Improper Payment Percentages for Hospice Services

For root cause descriptions of error categories for hospice services, see Table 4: Top Root Causes for Hospice.

*Other errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

When billing for hospice services, follow these certification requirements:

• As of June 3, 2024, we pay for hospice services only if certifying physicians, including hospice physicians and hospice attending physicians, are enrolled in or opted out of Medicare.
• The hospice medical director, a physician member of the hospice interdisciplinary group, or the patient’s attending physician must give hospices written certification of terminal illness for each election period, even if a single election continues for an unlimited number of periods.
• Payment normally starts with the effective date of election (the admission date). If the provider forgets to date the certification, the hospice can get a notarized statement or another acceptable document from the provider verifying the certification date.
• If the hospice medical director, a physician member of the hospice interdisciplinary group, or the patient’s attending physician can’t provide the hospice with written certification within 2 calendar days, they must provide oral certification within 2 calendar days. The hospice must get written certification before submitting a claim for payment.
• You may complete certifications no more than 15 calendar days before the election’s effective date. You may complete recertifications no more than 15 calendar days before the next benefit period’s effective date.
• For the first 90-day period, the hospice must get, no later than 2 calendar days after hospice care starts, oral or written certification from:
  • The hospice medical director, the physician designee, or a physician member of the hospice interdisciplinary group. The physician designee is a medical doctor or doctor of osteopathy who the hospice designates that assumes the same responsibilities and obligations as the medical director when the medical director isn’t available.
  • The patient’s attending physician, if they have one. Attending physicians must meet the definitions specified in 42 CFR 410.20.
• For subsequent periods, only the medical doctor of the hospice, physician designee, or physician member of the hospice interdisciplinary group needs to give the certification.
• Hospices must file written certification in the patient’s record before submitting a claim to the A/B and Home Health and Hospice Medicare Administrative Contractor (MAC). Hospices must file clinical information and other documentation that support the medical prognosis in the patient’s medical record with the written certification. The hospice physician may first provide clinical information verbally and then document it in the medical record and include it as part of the hospice’s eligibility assessment.

A complete written certification includes:

• A statement that the patient’s life expectancy is 6 months or less if the terminal illness runs its normal course.
• Specific clinical findings and other documentation supporting a life expectancy of 6 months or less.
• Provider signatures, date signed, and benefit period dates the certification or recertification covers.
• The provider’s brief narrative explaining clinical findings that support life expectancy of 6 months or less as part of the certification and recertification forms or as an addendum to them.
  • Place the narrative above the provider’s signature if it’s part of the certification or recertification form.
  • If the narrative exists as an addendum to the certification or recertification form or to the provider’s signature on the certification or recertification form, the provider must also sign the narrative in the addendum.
  • Narratives must include a statement directly above the provider’s signature that the provider confirms they composed the narrative based on their review of the patient’s medical record or, if applicable, their patient’s exam. Providers may dictate narratives.
  • Narratives must show the patient’s individual clinical circumstances and not include check boxes or standard language used for all patients. Providers must combine the patient’s comprehensive medical information to compose this brief clinical justification narrative.
  • For recertifications, the narrative associated with the third benefit period recertification and every following recertification must explain why clinical findings of the face-to-face encounter support life expectancy of 6 months or less.

Face-to-Face Encounter

For recertifications, a hospice physician or hospice nurse practitioner (NP) must have a face-to-face encounter with each hospice patient before the patient starts their third benefit period and before each following benefit period. Failure to meet face-to-face encounter requirements listed in Medicare Benefit Policy Manual, Chapter 9 results in the patient no longer being eligible for the benefit.

When billing for hospice services, remember:

• If recertification requires a face-to-face encounter and documentation of the encounter is missing, recertification isn’t complete. The statute requires a complete certification or recertification for us to cover and pay for hospice services.
• If the patient is no longer eligible for the hospice benefit because the hospice didn’t meet the face-to-face requirement, we expect the hospice to discharge the patient from the hospice benefit. The hospice must continue to care for the patient at its own expense until the required encounter occurs, allowing the hospice to re-establish eligibility. The hospice can re-admit the patient to the hospice benefit once the required encounter occurs if the patient continues to meet all eligibility requirements and the patient (or representative) files an election statement according to our regulations.
• Hospices must file written certification statements and keep them in their patients’ medical records. Hospice staff must make a proper entry in the patient’s medical record as soon as they get an oral certification.

Documentation Requirements

Example of Improper Payments Due to Insufficient Documentation for Certification of Illness

At the review contractor’s request, a hospice provider submits the following documentation to certify their patient is terminally ill:

• Physician authenticated certification of terminal illness for the benefit period that includes the physician’s attestation statement
• Election of Benefits statement
• Plan of care and physician’s orders
• Decline in clinical status worksheet authenticated by a nurse
• Visit notes by a nurse, aide, or social worker
• Admission nurse assessment
• Physical therapy evaluation
• Occupational therapy evaluation
• Hospital records

What Documentation Was Missing?

The certification of terminal illness was missing the physician’s brief narrative explanation of the clinical findings that support a life expectancy of 6 months or less.

What Happens Next?

The review contractor completes the claim as an insufficient documentation error, and the MAC recoups payment.

Recommendation

To justify payment and prevent claim denials and improper payments, the certifying physician must collect and submit proper documentation when billing hospice services.