For physicians, nurse practitioners and physician assistants

Who certifies terminal illness?

Under 42 CFR 418.22, the first 90-day benefit period requires certification by two physicians: the hospice medical director (or the physician member of the hospice interdisciplinary group) and the patient's attending physician, if the patient has one. For later benefit periods, only a hospice physician must recertify. Only a doctor of medicine or osteopathy can certify. A nurse practitioner or physician assistant can serve as attending but cannot certify terminal illness.

The certification states that the patient's prognosis is a life expectancy of six months or less if the terminal illness runs its normal course. It must be supported by clinical information in the record and include a brief narrative, written by the certifying physician, explaining the clinical findings behind the prognosis. If a written certification cannot be obtained within two calendar days of the start of care, a verbal certification is obtained within those two days and the written one follows before a claim is billed. CMS also requires that certifying physicians be enrolled in Medicare or have a valid opt-out on file.

Certification and recertification at a glance

The face-to-face encounter is the hospice's responsibility, not the attending physician's. The hospice physician or hospice nurse practitioner who performs it attests that the visit occurred, and the findings inform the recertification narrative.

What does the attending physician do?

The patient chooses the attending physician. It is the physician, nurse practitioner or physician assistant the patient identifies as having the most significant role in their medical care. A patient may also choose to have no attending and rely on the hospice physician.

As attending you can take part in the plan of care, receive updates from the hospice team, and continue to see the patient. If you are not employed by or under contract with the hospice, you continue to bill Medicare Part B for your professional services related to the terminal illness, and claims carry the GV modifier. Services unrelated to the terminal illness are billed with the GW modifier. Confirm current billing instructions with your Medicare Administrative Contractor. Medicines, equipment and other services related to the terminal illness are arranged and paid through the hospice under the plan of care.

Prognostic uncertainty: when to call

Medicare does not require certainty. The standard is clinical judgment about the normal course of the illness. Consider a call when you see:

• Decline in function, such as a Palliative Performance Scale or Karnofsky score that has fallen over recent months.
• Unintentional weight loss, falling albumin, or dysphagia with poor intake.
• Recurrent infections, or repeated hospital or emergency visits for the same illness.
• Disease progression despite optimal treatment, or a patient who declines further disease-directed treatment.
• A family asking what comes next.

When palliative care is the better referral

Some patients have a heavy symptom burden but are still pursuing disease-directed treatment, or do not have a six-month prognosis. Palliative care can run alongside that treatment. See palliative care referrals for general criteria and the Medi-Cal palliative care benefit.

How we communicate back to you

1. Step 1

   After the referral

   We tell you whether we reached the patient or family and whether an informational visit is scheduled, within two hours of your referral, 24 hours a day.

2. Step 2

   After the admission visit

   We tell you whether the patient elected hospice, the admitting diagnosis, and who the patient named as attending. If the patient was not admitted, we tell you why.

3. Step 3

   During care

   The hospice team contacts the attending about significant changes in condition, medication changes that need your order or awareness, and changes in level of care. Changes in condition are communicated in real time; routine updates go through the secure channel you prefer, at a frequency agreed with you, and each exchange is documented.

4. Step 4

   At discharge, revocation or death

   We notify the attending physician in real time.

Three ways to refer

Our response commitment: A response within two hours, 24 hours a day, 7 days a week

Common questions