Wednesday, October 2, 2019

A blog post about hospice eligibility that doesn't include the words criteria or guidelines


This looks like the place

Note the absence of "guidelines" and "criteria"

Here are the Medicare regulations. The words “criteria” and “guidelines” don’t appear here either.

§ 418.22 Certification of terminal illness
(DeathNurse abridged version)

The individual’s prognosis is for a life expectancy of 6 months or less if the illness runs its normal course, based on the physician’s or medical director’s clinical judgment regarding the individual’s illness. Clinical information and documentation that support the medical prognosis must accompany certification, and also include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less. The narrative must reflect the patient’s individual clinical circumstances and cannot contain check boxes or standard language used for all patients.

§ 418.22 Certification of terminal illness 
(excerpt)

(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/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.


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