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Compliance Tip Sheet

National Hospice and Palliative Care Organization www.nhpco.org/regulatory

Recertification of the Hospice Terminal Illness

Compliance Tip Sheet

Version 2, Revised March 2012

Contents of Tip Sheet · · · · Recertification process and requirements for a patient entering the second 90-day benefit period Recertification process and requirements for a patient entering the first 60-day benefit period and subsequent 60-day benefit periods Medicare recertification regulations Recertification resources

INTRODUCTION The hospice regulations for certification and recertification are included in the Medicare regulations at 42 CFR 418.22. The Centers for Medicare and Medicaid Services (CMS) made updates to the hospice certification and recertification regulations between 2005 and 2011 that radically change how a hospice provider completes these processes. The regulatory language appears later in this tip sheet. I. RECERTIFICATION OF TERMINAL ILLNESS FOR PATIENT ENTERING THE SECOND (2nd) 90-DAY BENEFIT PERIOD (b) CURRENT HOSPICE PATIENT WHO IS ELIGIBLE FOR HOSPICE SERVICES Who completes the recertification? · The hospice medical director or hospice physician o Only the hospice medical director or hospice physician is required to sign the recertification for a new admission to the second 90-day benefit period unless otherwise specified by state hospice licensure regulations o If state law requires an attending physician to sign the recertification, the hospice medical director/ hospice physician should compose the brief narrative statement NOTES: o No one other than a medical doctor or doctor of osteopathy can certify or re-certify a terminal illness. o A nurse practitioner (NP) may not recertify hospice terminal illness. Page 1 of 12

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The recertification process

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Timing of the recertification

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· Required components of the recertification Billing considerations · · · ·

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Hospice medical director / hospice physician signs the certificate of terminal illness form The hospice medical director / hospice physician composes the brief narrative statement and signs the attestation for the statement If the hospice cannot obtain the written certification within 2 calendar days, after a benefit period begins, it must obtain an oral certification within 2 calendar days and the written certification before it submits a claim for payment. For subsequent benefit periods, recertifications may be completed up to 15 days before the next benefit period begins. Recertification form ­ See NHPCO sample recertification forms Physician narrative statement Physician narrative attestation (placed above the physician signature) Documents that must be completed before billing: o Written / signed certification form o Physician narrative statement o Narrative attestation Hospices must use occurrence span code 77 to identify days of care that are not covered by Medicare due to untimely physician recertification. This is particularly important when the non-covered days fall at the beginning of a billing period If these requirements are not met, no payment is made for the days prior to the certification. Instead, payment begins with the day of certification, i.e., the date verbal certification (or written certification if that is done first) is obtained. If the physician forgets to date the certification, a notarized statement or some other acceptable documentation can be obtained to verify when the certification was obtained

(c) CURRENT HOSPICE PATIENT WHO IS NO LONGER ELIGIBLE FOR HOSPICE SERVICES · · If the patient is no longer eligible for hospice services, the hospice initiates the discharge process. Hospice providers must provide a minimum of 2 days notice prior to discharge. If state regulations are more stringent for the discharge notice, the provider would adhere to the stricter requirement.

(d) NEW ADMISSION TO THE SECOND (2nd) BENEFIT PERIOD If the patient is not assessed as eligible for hospice services, the hospice provider does not admit the patient. This is a recertification of terminal illness since it is the second benefit period, even though it is a new admission for your hospice.

Who completes the recertification?

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The hospice medical director or hospice physician o Only the hospice medical director or hospice physician is required to sign the recertification for a new admission to the Page 2 of 12

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second 90-day benefit period unless otherwise specified by state hospice licensure regulations.

o If state law requires an attending physician to sign the recertification, the hospice medical director/ hospice physician should compose the brief narrative statement.

· NOTES: No one other than a medical doctor or doctor of osteopathy can certify or re-certify a terminal illness. o A nurse practitioner (NP) may not recertify hospice terminal illness. Hospice provider checks the Medicare Common Working file (CWF) for previous hospice services. Hospice medical director / hospice physician signs the certificate of terminal illness form . The hospice medical director / hospice physician composes the brief narrative statement and signs the attestation for the statement. If the hospice cannot obtain the written certification within 2 calendar days after a benefit period begins, it must obtain an oral certification within 2 calendar days and the written certification before it submits a claim for payment. Recertifications may be completed up to 15 days before the next benefit period begins. Recertification form ­ See NHPCO sample recertification forms Physician narrative statement Physician narrative attestation (placed above the physician signature) Documents that must be completed before billing: o Written / signed certification form o Physician narrative statement o Narrative attestation Hospices must use occurrence span code 77 to identify days of care that are not covered by Medicare due to untimely physician recertification. This is particularly important when the non-covered days fall at the beginning of a billing period If these requirements are not met, no payment is made for the days prior to the certification. Instead, payment begins with the day of certification, i.e., the date verbal certification (or written certification if that is done first) is obtained. If the physician forgets to date the certification a notarized statement or some other acceptable documentation can be obtained to verify when the certification was obtained o

The recertification process

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Timing of the recertification

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· Required components of the recertification Billing considerations · · · ·

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Regulatory Citations for This Section · CMS Hospice Face­to-Face Encounter Requirements ­ effective January 1, 2011 with extension to April 1, 2011 ­ incorporated into 418.22(a)(4) http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol3/pdf/CFR-2011-title42-vol3-part418-subpartB.pdf

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Medicare Hospice Regulations with updated regulatory text at 418.22 ­ Certification of the Terminal Illness: http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol3/pdf/CFR-2011-title42-vol3-part418-subpartB.pdf Change Request 3686, Hospice Physician Recertification Requirements http://www.cms.gov/Transmittals/downloads/R458CP.pdf Change request 7337, New Hospice Certification Requirements and Revised Conditions of Participation (CoPs) March 2, 2011 - http://www.cms.gov/transmittals/downloads/R141BP.pdf

NHPCO Resources · Recertification of Terminal Illness Audit Checklist (PDF) Revised 11/18/2010 · Recertification of Terminal Illness Tip Sheet (PDF) Revised MAR 2011 · Sample Recertification of Terminal Illness forms and instructions for use (Word) Revised 11/18/2010

II.

RECERTIFICATION OF TERMINAL ILLNESS FOR PATIENT ENTERING THE 3RD (1ST 60-DAY) OR SUBSEQUENT BENEFIT PERIOD A. CURRENT HOSPICE PATIENT WHO IS ELIGIBLE FOR HOSPICE SERVICES Who completes the recertification? · The hospice medical director or hospice physician o Only the hospice medical director or hospice physician is required to sign the recertification for a new admission to the second 90-day benefit period unless otherwise specified by state hospice licensure regulations.

o If state law requires an attending physician to sign the recertification, the hospice medical director/ hospice physician should compose the brief narrative statement.

· NOTES: No one other than a medical doctor or doctor of osteopathy can certify or re-certify a terminal illness. o A nurse practitioner (NP) may not recertify hospice terminal illness. The hospice medical director or hospice physician o The hospice physician may be a direct hospice employee, contracted, or a volunteer. Hospice nurse practitioner (NP) o Nurse Practitioner (may not be contracted; must be a hospice W-2 employee or volunteer). o If the hospice is a subdivision of an agency or organization, an employee of the agency or organization who is assigned to the hospice is a hospice employee. NOTE: o Clinical Nurse Specialists or Physician Assistants are not authorized by CMS to complete a face-to-face visit. The physician or NP completes the face-to-face encounter, and signs the face-to-face encounter attestation which includes the patient's name and the date of the encounter. o Page 4 of 12

Who completes the face-toface encounter?

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The recertification process

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Required: If the NP or non-certifying hospice physician completes the face-to-face encounter, he/she communicates the findings to the hospice certifying physician for use in determining eligibility and composing brief physician narrative. Certifying hospice medical director / hospice physician signs the certificate of terminal illness form. The certifying hospice medical director / hospice physician composes the brief narrative statement and signs the narrative attestation statement. NOTE: o The same physician is not required to complete all components of the face-to-face requirement and must communicate findings to the physician who is completing the recertification documents. o The face-to-face encounter must be completed no more than 30 calendar days prior to the 3rd benefit period recertification, and no more than 30 calendar days prior to every recertification thereafter. Recertifications may be completed up to 15 days before the next benefit period begins. Face-to-face encounter Face-to-face attestation (placed above the physician signature) that includes: o The patient's name o The date of the visit o If the face-to-face encounter was provided by a NP, the attestation should include a statement that the clinical findings of that encounter have been provided to the certifying physician for use in determining continued eligibility for hospice care. o Signature & date by the NP or physician who made the visit Recertification form Physician brief narrative statement Physician narrative attestation (placed above the physician signature) NOTE: o While there is no requirement that the visit also be documented in the clinical record, NHPCO recommends that documentation of the date and time of the visit, who conducted the visit, and clinical findings be included in the clinical record. Before billing: o There must be a completed face-to-face encounter and accompanying attestation statement. o There must be a written / signed certification and before a hospice provider submits a claim for payment. o There must be a completed physician narrative and physician narrative attestation statement.

Timing of the recertification

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· Required components of the recertification ·

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Billing considerations

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NOTE: · If these requirements are not met, no payment is made for the days prior to the certification. Instead, payment begins with the day of certification, i.e., the date verbal certification (or written certification if that is done first) is obtained. If the physician forgets to date the certification a notarized statement or some other acceptable documentation can be obtained to verify when the certification was obtained.

B. MISSED/ LATE FACE-TO-FACE ENCOUNTER FOR CURRENT PATIENT ENTERING THIRD (3RD) (1ST 60-DAY) OR SUBSEQUENT BENEFIT PERIOD Who completes the recertification? · The hospice medical director or hospice physician. The same physician is not required to complete all components of the face-to-face requirement. o Only the hospice medical director or hospice physician is required to sign the recertification for a new admission to the second 90-day benefit period unless otherwise specified by state hospice licensure regulations.

o If state law requires an attending physician to sign the recertification, the hospice medical director/ hospice physician should compose the brief narrative statement.

· NOTES: No one other than a medical doctor or doctor of osteopathy can certify or re-certify a terminal illness. o A nurse practitioner (NP) may not recertify hospice terminal illness. The hospice medical director or hospice physician o The hospice physician may be a direct hospice employee, contracted, or a volunteer. Hospice nurse practitioner (NP) o Nurse Practitioner (may not be contracted; must be a hospice W-2 employee or volunteer). o If the hospice is a subdivision of an agency or organization, an employee of the agency or organization who is assigned to the hospice is a hospice employee. NOTE: o Clinical Nurse Specialists or Physician Assistants are not authorized by CMS to complete a face-to-face visit. If the patient remains eligible for next benefit period but the face-to-face encounter was missed/ late, the patient ceases to be eligible for the Medicare Hospice Benefit and must be discharged from the Medicare Hospice Benefit. An NP or physician must complete a face-to-face encounter prior to readmitting the patient back to the Medicare Hospice Benefit. The re-admission should be treated as a new admission to the Medicare Hospice Benefit. The physician or NP completes the face-to-face encounter, and signs the faceo Page 6 of 12

Who completes the faceto-face encounter?

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The recertification process

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· Required components of the recertification for a missed face-to-face encounter · ·

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Billing considerations · · · ·

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to-face encounter attestation which includes the patient's name and the date of the encounter. o Required: If the NP or non-certifying hospice physician completes the face-to-face encounter, he/she communicates the findings to the hospice certifying physician for use in determining eligibility and composing narrative. Certifying hospice medical director / hospice physician signs the certificate of terminal illness form. The certifying hospice medical director / hospice physician composes the brief narrative statement and signs the narrative attestation statement. The face-to-face encounter must be completed no more than 30 calendar days prior to the 3rd benefit period recertification, and no more than 30 calendar days prior to every recertification thereafter. Recertifications may be completed up to 15 days before the next benefit period begins. Face-to-face encounter Face-to-face attestation (placed above the physician signature) that includes: o The patient's name o The date of the visit o If the face-to-face encounter was provided by a NP, the attestation should include a statement that the clinical findings of that encounter have been provided to the certifying physician for use in determining continued eligibility for hospice care. o Signature & date by the NP or physician who made the visit While there is no requirement that the visit also be documented in the clinical record, NHPCO recommends that documentation of the date and time of the visit, who conducted the visit, and clinical findings be included in the clinical record. Recertification form Physician narrative statement Physician narrative attestation (placed above the physician signature) If there is a missed/late face-to-face encounter, billing to Medicare must discontinue at discharge. The patient remains on hospice service at the hospice provider's expense until the required face-to-face encounter occurs, enabling the hospice to re-establish Medicare eligibility. Billing to Medicare may resume after the completion of the face- to face encounter for the next benefit period. Before billing: o There must be a completed face-to-face encounter and accompanying attestation statement. o There must be a written / signed certification and before a hospice provider submits a claim for payment. o There must be a completed physician narrative and physician narrative attestation statement. If these requirements are not met, no payment is made for the days prior to the Page 7 of 12

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certification. Instead, payment begins with the day of certification, i.e., the date verbal certification (or written certification if that is done first) is obtained. If the physician forgets to date the certification a notarized statement or some other acceptable documentation can be obtained to verify when the certification was obtained .

C. CURRENT HOSPICE PATIENT WHO IS NO LONGER ELIGIBLE FOR HOSPICE SERVICES · · If the patient is no longer eligible for hospice services, the hospice initiates the discharge process. Hospice providers must provide a minimum of 2 days notice prior to discharge. If state regulations are more stringent for discharge notice, the provider would adhere to the stricter requirement.

(e) NEW ADMISSION TO THE THIRD 3RD (1ST 60-DAY) OR SUBSEQUENT BENEFIT PERIOD Who completes the recertification? · The hospice medical director or hospice physician o Only the hospice medical director or hospice physician is required to sign the recertification for a new admission to the second 90-day benefit period unless otherwise specified by state hospice licensure regulations.

o If state law requires an attending physician to sign the recertification, the hospice medical director/ hospice physician should compose the brief narrative statement.

· NOTES: No one other than a medical doctor or doctor of osteopathy can certify or re-certify a terminal illness. o A nurse practitioner (NP) may not recertify hospice terminal illness. The hospice medical director or hospice physician o The hospice physician may be a direct hospice employee, contracted, or a volunteer. Hospice nurse practitioner (NP) o Nurse Practitioner (may not be contracted; must be a hospice W-2 employee or volunteer). o If the hospice is a subdivision of an agency or organization, an employee of the agency or organization who is assigned to the hospice is a hospice employee. NOTE: o Clinical Nurse Specialists or Physician Assistants are not authorized by CMS to complete a face-to-face visit. The physician or NP completes the face-to-face encounter, and signs the faceto-face encounter attestation which includes the patient's name and the date of the encounter. o Required: If the NP or non-certifying hospice physician completes the face-to-face encounter, he/she communicates the findings to the hospice certifying physician for use in determining eligibility and composing narrative. Certifying hospice medical director / hospice physician signs the certificate of o Page 8 of 12

Who completes the faceto-face encounter?

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Timing of the recertification

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terminal illness form. The certifying hospice medical director / hospice physician composes the brief narrative statement and signs the narrative attestation statement. NOTE: o The same physician is not required to complete all components of the face-to-face requirement and must communicate findings to the physician who is completing the recertification documents. The face-to-face encounter must be completed prior to the start of the benefit period. If the hospice cannot obtain the written certification within 2 calendar days, after a benefit period begins, it must obtain an oral certification within 2 calendar days and the written certification before it submits a claim for payment. Recertifications may be completed up to 15 days before the next benefit period begins. Face-to-face encounter Face-to-face attestation (placed above the physician signature) that includes: o The patient's name o The date of the visit o If the face-to-face encounter was provided by a NP, the attestation should include a statement that the clinical findings of that encounter have been provided to the certifying physician for use in determining continued eligibility for hospice care. o Signature & date by the NP or physician who made the visit While there is no requirement that the visit also be documented in the clinical record, NHPCO recommends that documentation of the date and time of the visit, who conducted the visit, and clinical findings be included in the clinical record. Recertification form Physician narrative statement Physician narrative attestation (placed above the physician signature) Before billing: o There must be a completed face-to-face encounter and accompanying attestation statement. o There must be a written / signed certification and before a hospice provider submits a claim for payment. o There must be a completed physician narrative and physician narrative attestation statement. If these requirements are not met, no payment is made for the days prior to the certification. Instead, payment begins with the day of certification, i.e., the date verbal certification (or written certification if that is done first) is obtained. If the physician forgets to date the certification a notarized statement or some other acceptable documentation can be obtained to verify when the certification was obtained.

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Regulatory Citations for This Section · CMS Hospice Face­to-Face Encounter Requirements ­ effective January 1, 2011 with extension to April 1, 2011 ­ incorporated into 418.22(a)(4) http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol3/pdf/CFR-2011-title42-vol3-part418-subpartB.pdf Medicare Hospice Regulations with Updated regulatory text at 418.22 ­ Certification of the Terminal Illness http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol3/pdf/CFR-2011-title42-vol3-part418-subpartB.pdf Change Request 3686, Hospice Physician Recertification Requirements http://www.cms.gov/Transmittals/downloads/R458CP.pdf Change request 7337, New Hospice Certification Requirements and Revised Conditions of Participation (CoPs) -- March 2, 2011 - http://www.cms.gov/transmittals/downloads/R141BP.pdf FY 2012 Final Hospice Wage Index ,CMS- 1355­F, AUG 4, 2011 - http://www.gpo.gov/fdsys/pkg/FR-2011-0804/pdf/2011-19488.pdf CR 7478, CMS, October 7, 2011 - https://www.cms.gov/transmittals/downloads/R2316CP.pdf CR 7677, CMS, February 3, 2012 - https://www.cms.gov/transmittals/downloads/R2410CP.pdf

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NHPCO Resources · · · Recertification of Terminal Illness Audit Checklist (PDF) Revised 11/18/2010 Recertification of Terminal Illness tip sheet (PDF) Revised March 2011 Sample Recertification of Terminal Illness forms and instructions for use (Word) Revised 11/18/2010

The Medicare Regulations

The following table outlines the recent regulatory revisions and the implementation year. Recertification regulations Physician narrative requirement Face-to-face encounter final rule Change Request 7337 Change Request 7478 Change Request 7677 Effective date October 1, 2009 January 1, 2011 March 23, 2011 January 9, 2012 July 1. 2012 Link to regulation http://edocket.access.gpo.gov/2009/pdf/E9-18553.pdf http://edocket.access.gpo.gov/2010/pdf/2010-27778.pdf https://www.cms.gov/transmittals/downloads/R141BP.pdf https://www.cms.gov/transmittals/downloads/R2316CP.pdf https://www.cms.gov/transmittals/downloads/R2410CP.pdf

Sec. 418.22 Certification of terminal illness. (a) Timing of certification-- (1) General rule. The hospice must obtain written certification of terminal illness for each of the periods listed in § 418.21, even if a single election continues in effect for an unlimited number of periods, as provided in § 418.24(c). (2) Basic requirement. Except as provided in paragraph (a)(3) of this section, the hospice must obtain the written certification before it submits a claim for payment.

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(3)

(4)

Exceptions. (i) If the hospice cannot obtain the written certification within 2 calendar days, after a period begins, it must obtain an oral certification within 2 calendar days and the written certification before it submits a claim for payment. (ii) Certifications may be completed no more than 15 calendar days prior to the effective date of election. (iii) Recertifications may be completed no more than 15 calendar days prior to the start of the subsequent benefit period. Face-to-face encounter. As of January 1, 2011, a hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient whose total stay across all hospices is anticipated to reach the 3rd benefit period. The face-to-face encounter must occur prior to, but no more than 30 days prior to, the 3rd benefit period recertification, and every benefit period reconciliation thereafter, to gather clinical findings to determine continued eligibility for hospice care.

(b) Content of certification. Certification will be based on the physician's or medical director's clinical judgment regarding the normal course of the individual's illness. The certification must conform to the following requirements: (1) The certification must specify that the individual's prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course. (2) Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification as set forth in paragraph (d)(2) of this section. Initially, the clinical information may be provided verbally, and must be documented in the medical record and included as part of the hospice's eligibility assessment. (3) The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms. (i) If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician's signature. (ii) If the narrative exists as an addendum to the certification or recertification form, in addition to the physician's signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum. (iii) The narrative shall include a statement directly above the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient's medical record or, if applicable, his or her examination of the patient. (iv) The narrative must reflect the patient's individual clinical circumstances and cannot contain check boxes or standard language used for all patients. (v) The narrative associated with the 3rd benefit 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 6 months or less. (4) The physician or nurse practitioner who performs the face-to-face encounter with the patient described in (a) (4) of this section must attest in writing that he or she had a face-to-face encounter with the patient, including the date of that visit. The attestation of the nurse practitioner or a non© National Hospice and Palliative Care Organization, Version 2, Revised March 2012

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certifying hospice physician shall state that the clinical findings of that visit were provided to the certifying physician for use in determining continued eligibility for hospice care. (5) All certifications and recertifications must be signed and dated by the physician(s), and must include the benefit period dates to which the certification or recertification applies. (c) Sources of certification. (1) For the initial 90-day period, the hospice must obtain written certification statements (and oral certification statements if required under paragraph (a)(3) of this section) from-(i) The medical director of the hospice or the physician member of the hospice interdisciplinary group; and (ii) The individual's attending physician if the individual has an attending physician. The attending physician must meet the definition of physician specified in § 418.20 of this subchapter. (2) For subsequent periods, the only requirement is certification by one of the physicians listed in paragraph (c)(1)(i) of this section. [48 FR 56026, Dec. 16, 1983, as amended 70 FR 45144, August 4, 2005]

(d) Maintenance of records. Hospice staff must-(1) Make an appropriate entry in the patient's medical record as soon as they receive an oral certification; and (2) File written certifications in the medical record. Link to Federal Regulations: 42 CFR 418.22 http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol3/pdf/CFR-2011-title42-vol3-part418-subpartB.pdf

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