(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.
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