When a terminally ill patient chooses hospice, families and clinicians alike are counting on your team to step in and provide the care and clarity they need. But even if you deliver flawless care, Medicare won’t pay unless your documentation meets very specific requirements. One missed signature, one vague prognosis, and your claim could be denied.
Whether you're new to hospice or looking to tighten your processes, understanding the ins and outs of Medicare’s hospice certification is essential: not just for compliance, but for ensuring your agency gets paid.
*This article was written in consultation with Mariam Treystman.
At The Home Health Consultant, we’ve supported hundreds of Medicare-certified hospice agencies through surveys, ADRs, and appeals. Our founder, Mariam Treystman, puts it simply: “With hospice eligibility, the rules are pretty clear cut. If your claims are getting denied, it’s usually not a documentation gray area. It’s that something important is missing.”
In this article, we’ll walk you through the key criteria for certifying and recertifying hospice patients under Medicare, so you can avoid costly denials and keep your agency running smoothly.
What Does Medicare Require to Certify a Hospice Patient?
To admit a patient into hospice under Medicare, the following criteria must be clearly documented and supported:
1. Terminal Illness Prognosis
The patient must have a terminal illness with a medical prognosis of six months or less to live—if the illness runs its normal course. This determination must be based on clinical judgment.
2. Physician Certification
A physician must certify that the patient is terminally ill. Specifically:
- For the initial certification, both the hospice medical director (or a physician member of the IDG) and the patient’s attending physician (if they have one) must sign.
- For recertifications, only the hospice physician is required to sign.
It’s also important to note, hospice agencies employ their own physicians in-house, aka your medical director. A patient can either use your agency’s physician to direct the hospice care, or keep their own doctor.
If the patient keeps their own doctor as the attending, both physicians need to certify. If they opt out of using their own doctor, the hospice’s medical director manages everything and signs solo.
3. Hospice Certification Timing Requirements
Medicare allows for:
- Certification up to 15 days before the start of a benefit period
- Or no later than 2 calendar days after the benefit period begins
This timeline applies to both initial certifications and recertifications.
However, documentation must be complete before billing. If your billing date comes before the signed certification is back in your office, that claim is at risk of denial even if the care was delivered perfectly.
What Must Be Included in the Certification or Recertification?
Medicare doesn’t just require a signature. They requires a detailed explanation. According to CGS and CMS, the certification or recertification must include:
- A statement confirming the patient’s prognosis is six months or less
- A physician attestation confirming they personally composed the narrative based on review of the record or examination of the patient
- Benefit period dates that the certification covers
- A brief narrative explaining the clinical findings that support this prognosis
This narrative:
- Must be written by the certifying physician only
- Cannot be templated or pre-filled with checkboxes
- Must appear directly above the physician’s signature if included on the form
- If narrative is included as an addendum, the physician must sign immediately after the narrative
And starting with the third benefit period, the narrative must also explain how the findings of the Face-to-Face encounter support the six-month prognosis.
When patients are admitted to hospice, their physician certifies they have a 6-month prognosis. The first two 60-day benefit periods cover those six months. So, any time spent in hospice care beyond the two initial benefit periods, is unexpected. This is why CMS has additional requirements for documentation starting with the third benefit period.
The end of the first two benefit periods (6-months) also signifies your agency has reached their hospice cap for that patient. For a more in-depth breakdown of hospice caps and how they work, check out the article below.
What Is the Medicare Face-to-Face Encounter Requirement for Hospice?
Medicare requires a Face-to-Face (FTF) encounter starting in the third benefit period and for every benefit period after that.
This must be completed within 30 days prior to the recertification and documented with:
- The date of the encounter
- An attestation by the physician or nurse practitioner that the visit occurred
- A statement that the findings were used to support the prognosis
If a nurse practitioner performs the face-to-face (FTF), they must attest that they shared their findings with the certifying physician, who then uses them to compose the narrative.
Who Is Allowed to Sign Hospice Certifications?
Only certain providers can sign a valid certification:
Who is Allowed to Sign a Hospice Certification:
- Hospice medical director
- Physician member of the IDG
- Patient’s attending physician (must be an M.D. or D.O.)
Who is Not Allowed to Sign a Hospice Certification:
- Nurse practitioners
- Physician assistants
- Stamped signatures
- Undated or illegible signatures
Acceptable signature formats include:
- Handwritten (with date)
- Electronic (with date)
- Faxed copies of handwritten or electronic originals (with date)
What Are the Most Common Hospice Certification Mistakes Agencies Make?
Even experienced agencies slip up on the technicalities. According to CGS, common errors include:
- Missing physician narratives
- Narratives without an attestation statement
- Verbal certifications not obtained when written ones are delayed
- Signatures that are missing, undated, or illegible
- Benefit period dates left out
- Certification signed after billing
As Mariam Treystman explains it:
“Medicare isn’t lenient when it comes to the technical side. If your documentation doesn’t align exactly with the requirements—even if your care was excellent—you could lose the full claim amount.”
What Happens If a Patient Revokes Hospice?
Patients must elect hospice before services begin, acknowledging they understand hospice is palliative and not curative. This is not just a formality: it's a Medicare requirement.
Once elected, Medicare will not cover any curative treatment unrelated to the terminal illness. However, patients may revoke hospice at any time and pursue other treatments. But doing so formally ends the hospice benefit period.
How Often Must Hospice Patients Be Recertified?
Medicare requires recertification at the start of each benefit period. The timeline for hospice benefit periods is:
- Initial benefit period – 90 days
- Second benefit period – 90 days
- Subsequent benefit periods – 60 days (recertification required for each)
Each time, the certification process must be repeated with a new physician narrative. Also, don’t forget that, starting with the third period, another Face-to-Face encounter is required as well.
Additionally, care plans must be updated every 15 days by the interdisciplinary group (IDG).
How Can Your Hospice Agency Stay Compliant with Medicare Certification and Recertification Rules?
To admit and continue caring for hospice patients under Medicare, your agency must follow a clear set of certification and recertification requirements.
Even small technical errors, like a missing date or unsigned narrative. can trigger full claim denials. These aren’t partial adjustments. When a hospice claim is denied, you’re not just losing reimbursement, you’re losing real money you already spent on staffing and services.
We always suggest implementing an internal audit process. Train your team to spot the most common documentation gaps. And never bill before certifications are fully signed and dated. If you're not confident that your processes are airtight, now’s the time to act.
Need help tightening up your hospice documentation process? Let’s make sure your certifications, recertifications, and Face-to-Face protocols are survey- and ADR-ready. Learn more about our Administrative Compliance Program below, or reach out today to learn how we can support your team.
*Disclaimer: The content provided in this article is not intended to be, nor should it be construed as, legal, financial, or professional advice. No consultant-client relationship is established by engaging with this content. You should seek the advice of a qualified attorney, financial advisor, or other professional regarding any legal or business matters. The consultant assumes no liability for any actions taken based on the information provided.
