Hospice Recertification Checklist

Hospice Benefit Periods at a Glance

Under 42 CFR 418.21, a patient elects an initial 90-day period, a second 90-day period, and an unlimited number of 60-day periods after that. Each period needs its own written certification, even when a single election continues.

Only a doctor of medicine or osteopathy can certify or recertify terminal illness. Nurse practitioners and physician assistants cannot, even when one serves as the patient's attending.

Recertification Timing Rules

• Earliest date: complete the recertification no more than 15 calendar days before the next benefit period begins.
• Deadline: the hospice must obtain the written recertification no later than 2 calendar days after the first day of the period. If it cannot, it must obtain an oral recertification within those 2 days and record it in the medical record right away.
• Before billing: the written recertification must be on file before the hospice submits a claim.
• Supporting records: clinical information supporting the prognosis must accompany the certification and be filed in the medical record with it.

Checklist 1: 30 Days Before the Benefit Period

• Confirm the patient's benefit period number and exact dates, including periods used at a prior hospice
• For the 3rd period or later: schedule the face-to-face encounter inside the 30-day window before the period starts
• Confirm the encounter practitioner is a hospice physician (employed or under contract) or a hospice-employed NP
• Pull trend data for the period: PPS, FAST (dementia), weights, mid-arm circumference, intake, ADL dependence, wounds, symptoms, ER visits and hospitalizations
• Pull your MAC's LCD criteria for the terminal diagnosis
• Put the patient on the IDG agenda before the recertification date

Checklist 2: The Face-to-Face Encounter (3rd Period Onward)

The face-to-face rule in 42 CFR 418.22(a)(4) exists to gather clinical findings for the recertification. Missing it ends eligibility, so treat it as a hard deadline.

• Encounter occurs no more than 30 calendar days before the period starts. Day 1 of the period still counts.
• Performed by a hospice physician or hospice NP. Not a PA, clinical nurse specialist, or outside attending physician.
• Practitioner attests in writing to the encounter and its date, signs, and dates the attestation
• Attestation is a clearly titled section of or addendum to the recertification form, or a signed and dated clinical note showing the encounter occurred
• If an NP or non-certifying physician performed it and the attestation is on the form or an addendum: the attestation states the findings were provided to the certifying physician
• Clinical findings are documented in enough detail for the certifying physician to use in the narrative
• New admission already in the 3rd or later period: if documented exceptional circumstances prevent an earlier visit, an encounter within 2 days after admission counts as timely

If the encounter is missed: the recertification is incomplete and the patient is no longer eligible. CMS expects the hospice to discharge the patient from the Medicare benefit, keep providing care at its own expense, and readmit once the encounter occurs, as long as the patient still meets eligibility and files a new election statement.

Telehealth: the Consolidated Appropriations Act, 2026 extended telehealth face-to-face encounters through December 31, 2027, with limits starting January 31, 2026. Telehealth is not allowed for hospices in a provisional period of enhanced oversight, for patients in an area under a CMS hospice enrollment moratorium, or for practitioners not enrolled in or opted out of Medicare (National Alliance for Care at Home summary). Confirm with your MAC before you rely on it.

Checklist 3: The Recertification and Physician Narrative

The certification of terminal illness (CTI) content rules in 42 CFR 418.22(b) apply to every recertification. Use this list before the physician signs.

• States the patient's life expectancy is 6 months or less if the terminal illness runs its normal course
• Includes specific clinical findings and other documentation supporting the prognosis
• Includes the physician's brief narrative explaining those findings, composed by the physician (dictation is allowed)
• Narrative sits immediately above the physician's signature, or in an addendum the physician signs right after the narrative
• Attestation directly above the signature confirms the physician composed the narrative from a review of the medical record or an exam of the patient
• Narrative reflects this patient's clinical picture. No check boxes, no standard language used for every patient.
• 3rd period onward: narrative explains why the face-to-face findings support a life expectancy of 6 months or less
• Signed and dated by the physician, with the benefit period dates the recertification covers
• Signed by the hospice medical director or physician member of the IDG (MD or DO)

For a four-part narrative structure and two worked examples, see hospice CTI and recertification narrative examples. For what reviewers look for in a narrative, including long-stay patients, see how to write strong hospice recertification narratives.

Checklist 4: Documenting Decline

A diagnosis alone does not support a terminal prognosis. Reviewers look for measurable findings with a baseline and a follow-up value. The non-disease-specific guidelines in CGS's LCD L34538, Hospice Determining Terminal Status, list these indicators of decline. Your MAC's LCD governs your claims, so check it for disease-specific criteria.

• Every indicator has a baseline value and a current value with dates
• The same tools (PPS, FAST) are scored the same way across periods
• Visit notes from the period match the decline the narrative describes
• For a patient who looks stable: the record explains what severity persists and why the prognosis still holds

Checklist 5: IDG Review

Under 42 CFR 418.56, the interdisciplinary group (a physician, a registered nurse, a social worker, and a pastoral or other counselor) reviews and updates the plan of care as often as the patient's condition requires, and at least every 15 calendar days. Under 42 CFR 418.102(c), the medical director, physician designee, or physician member of the IDG reviews the patient's clinical information before each recertification.

• IDG plan of care reviews documented at least every 15 calendar days
• Physician review of clinical information documented before the recertification
• IDG notes describe the same clinical picture as the narrative and visit notes
• Plan of care updated to reflect the decline and new interventions

For IDG tooling, see IDG documentation software.

Common Recertification Denial Reasons

CMS's hospice compliance tips name insufficient documentation as the leading cause of improper hospice payments. At recertification, it shows up in these forms:

1. Terminal prognosis not supported. The record shows a diagnosis but no measurable decline or persistent severity.
2. Missing or deficient narrative. No narrative, a narrative in the wrong place, a missing attestation, or standard language reused across patients.
3. Face-to-face problems. Encounter outside the 30-day window, performed by an ineligible practitioner, or missing a valid attestation.
4. Narrative ignores the face-to-face. From the 3rd period on, the narrative must explain how the encounter findings support the prognosis.
5. Signature and dating errors. Unsigned or undated recertifications, missing benefit period dates, or a written recertification not on file before the claim.
6. Contradictions in the chart. A narrative describing decline while visit notes read "no change."

When a review request arrives, the same documents are the core of the response. See our hospice ADR guide for what auditors request.

Catch Documentation Gaps Earlier

Recertification evidence comes from visit notes written over the whole benefit period. Sentinel QA runs automated QA on home health and hospice visit notes against your agency's rules, and flags documentation gaps so your QA team corrects them while the period is still open.

Sources

• 42 CFR 418.22, Certification of terminal illness
• 42 CFR 418.21, Duration of hospice care coverage
• Medicare Benefit Policy Manual, Chapter 9, section 20.1 (Rev. 13664, March 2026)
• 42 CFR 418.56, IDG and plan of care and 42 CFR 418.102, Medical director
• CGS, Hospice Terminal Prognosis: Non-Disease Specific (LCD L34538)
• CMS MLN, Medicare Provider Compliance Tips: Hospice Services