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Ever-Changing Hospice Basics
Update on What Every Hospice
Medical Director Needs to Know
The Hospice Medical Director
• The role of the physician is a centerpiece in the
Medicare Hospice Conditions of Participation.
• The Medical Director oversee the medical
component of the hospice patient care program.
• The hospice contracts with one Medical Director, and
other Associate Medical Directors.
Medical Director Has an Important Role
Certifications and Recertifications (including narratives)
Face-to-Face Encounters
Related/Unrelated Determinations
Medication Review and Expertise
Medically Necessary Visits
Quality Program
The Hospice Medical Director
• The hospice medical director, and other members of
the interdisciplinary team, collaborate with the
patient’s attending physician, communicating the
patient’s wishes and status.
• The medical director/associate medical director has
responsibility for the medical component of the
patient’s care.
The MD Must Approve the Hospice Admission
“The hospice admits a patient only on the recommendation of the medical director
in consultation with, or with input from, the patient’s attending physician (if any).”
How this works:
• The admission nurse obtains information from the attending,
the medical record, and the patient and then communicates
it to the medical director.
• At that time, the medical director provides recommendation
to admit and provides verbal certification of terminal illness
(CTI), if eligible.
Benefit Periods
• Hospice care is provided in benefit periods.
• Benefit periods are: 90, 90, 60, 60, 60….
– Two initial 90-day periods
– All subsequent are 60-day periods
• Every benefit period requires a certification of
terminal illness
Benefit Period CTIs
• 1st – CTI from attending and medical director
• 2nd – CTI from medical director only
• 3rd and all subsequent – Face-to-face encounter,
then CTI from medical director (in that order)
Verbal Certification of Terminal Illness (CTI)
• A verbal CTI allows the hospice to begin providing
hospice services.
• However – the written CTI must be completed before
the hospice can begin submitting billing to Medicare.
• Verbal CTI is required from the attending and also
the Medical Director.
Verbal CTI
Certification of Terminal Illness
• Verbal CTI may be obtained:
– Not earlier than 15 days before the start of the
benefit; and
– Not later than 48 hours after the first day of the
benefit period.
• Requires communication between the nurse and
the physician
Written CTI
Certification of Terminal Illness
• Requires signature and date of the certifying
physician (plus a narrative from the certifying
medical director)
• The signature confirms the medical opinion that the
patient has a life expectance of 6 months or less, if
the disease follows its normal course.
Written CTI: Narrative
Certification of Terminal Illness
• The medical director must also write a brief, but specific,
narrative that describes the patient’s clinical circumstances
and factors that support a life expectancy of 6 months or less.
• Narratives associated with the third or > benefit period
recertifications must include an explanation of why the
clinical findings of the face-to-face encounter support a life
expectancy of 6 months or less.
• An attestation that physician personally composed the
narrative is part of the CTI document and is required by CMS.
Face-to-Face Encounters
Benefit Periods
• Prior to the 3rd benefit period – and every benefit
period thereafter – a hospice physician or hospice
nurse practitioner must complete and document a
face-to-face encounter.
• CTI must include an attestation of the F2F encounter,
signed and dated by the person performing the F2F.
• The findings of the F2F are communicated to the
certifying physician.
Written CTI: Signatures/Dates
Certification of Terminal Illness
• All dates on signatures must be the actual day the
physician signed the document (no backdating)
– No stamped signature or stamped dates are
allowed by CMS; but
– Electronically affixed signatures and electronically
affixed dates are allowed.
Written CTI: Signatures
Certification of Terminal Illness
• Practice partners cannot sign for each other (per the
Medicare Integrity Manual)
• The physician who gave the order must be the
physician who signs the order.
Interdisciplinary Team Meeting (IDT)
• An IDT meeting/updated plan of care is required at
least every 14-15 days:
– 14 days (most states)
– 15 days (federal)
• The medical director is a core team member and
must participate to have a valid team meeting/
updated plan of care.
Leading the IDT Meeting
• It is the medical director’s role to help lead and
facilitate the IDT meeting. Content includes:
– Discussion of ongoing eligibility evidence for each
patient discussed
– Review of patient plan of care/problems and
progress towards goal/revising plan of care as
Leading the IDT Meeting
• IDT members are accountable for being prepared
for the meeting.
• Members are responsible for giving a concise and
objective report about the patient to the other core
Medical Diagnoses and Relatedness
• The medical director must provide brief
documentation regarding diagnoses related and
unrelated to the terminal diagnosis/prognosis.
• For those unrelated, must explain why it is unrelated.
• The medical director must provide brief
documentation regarding medications related and
unrelated to the terminal diagnosis/prognosis.
Medication Review and Management
• The medical director has a primary responsibility (can be
with the attending) to review each patient’s medications for:
- Therapeutic effectiveness
- Side effects
- Interactions
- Duplications
- Needed lab monitoring
• Make recommendations and give orders as needed to
discontinue, add new, or make adjustments to patient
Medical Director Role in Quality
The medical director’s engagement and ownership
of quality is crucial to the success of each hospice
Medical Director Role in Quality
• The medical director must participate at each
quality meeting and take an active role in
promoting quality outcomes:
– Educating the team, as needed
– Asking the right questions to find out what
happened when an outcome is not good
– Applying expertise
Levels of Care
• There are 4 levels of care:
Routine home care
General inpatient care
Continuous care
The 4 Levels of Care
1. Routine Home Care:
– Performed wherever the patient calls home:
• Personal home
• Assisted living facility
• Long-term care facility
The 4 Levels of Care
2. Respite:
– Custodial care performed in a contracted facility, for not
longer than 5 consecutive days.
– Relieves exhausted family members are exhausted or
when family is temporarily unable to continue care.
– The frequency hospice can perform respite is
“occasionally” and must always be accompanied by clear
documentation of family circumstances requiring this
level of care.
The 4 Levels of Care
3. General Inpatient (GIP) Care:
– Brief inpatient care to provide skilled care that cannot be
provided in the patient’s home.
– Requires order from medical director for admission into
and discharge out of GIP.
– Must be accompanied by explicit documentation of
ongoing need and interventions every day in GIP.
– Dying without crisis symptoms does not qualify for GIP.
The 4 Levels of Care
4. Continuous Care (CC):
– Brief periods of skilled care provided in the patient’s
place of residence.
– CC is in response to a physical crisis requiring this level of
skilled care to maintain the patient in his or her home.
– Must be accompanied by explicit documentation of
ongoing crisis need and interventions, hourly.
– There are specific rules about the required time that can
be billed to CMS for this level of care.
Very limited number of reasons a patient can be discharged
from hospice:
• Death
• Revocation
Patient makes the decision to revoke the hospice
services and hospice benefit
• Patient out
of service
This includes inpatient in non-contracted facility.
(The patient may temporarily leave the service and
the hospice contracts with another hospice to
provide hospice services on our behalf without
Very limited number of reasons a patient can be discharged
from hospice:
• Condition
The patient’s condition improves such that he or she
is no longer considered eligible for hospice.
• For cause
Includes situations where patient safety or hospice
staff safety is compromised. The patient (or other
persons in the patient’s home) behavior is disruptive,
abusive or uncooperative to the extent that delivery
of care to the patient of the ability of the hospice to
Must a patient be discharged if he or she exceeds 6
months on service?
Patients may stay on hospice as long as they meet
medical eligibility with a continued expectation of
prognosis 6 months or less, if the disease runs its
normal course. This must be accompanied by objective
and reasonable data to support that prognosis.
Are there a limited number of diagnoses for which
hospice can provide care?
Hospice sees a lot of the same kinds of terminal
illnesses, but there is not a limited number of
diagnoses that may be causing the patient’s terminal
status. Whatever the diagnosis, the documentation
must support a hospice prognosis.
Does the hospice medical director always become the
attending physician?
No. Patients determine who will be the attending, if any. It
may be a physician or an NP. In cases in which there is no
attending, or when the attending does not wish to
continue in the role of attending, the patient may request
that the medical director become the attending. The
medical director is responsible to over see the medical
component of the patient’s care.
What does hospice provide?
All visits, medications, supplies and DME related to
the terminal prognosis. All of those should be billed to
the hospice, rather than Medicare or Medicaid. The
only things that are billed outside of the hospice
benefit are things that are clearly unrelated to the
terminal illness/prognosis.
• The hospice rules are subject to relatively frequent
changes or reinterpretations by CMS, Medicaid and
state licensing agencies.
• Compassus will keep you and your program informed
of those changes.
• The importance of the Medical Director in each
program cannot be overstated. WE APPRECIATE YOU!