15.2 Hospice Eligibility, Admission, and Recertification

Eligibility is a prognosis, not a diagnosis tattoo

§ 418.20 and § 418.22 define eligibility: the individual is entitled to Medicare Part A and is terminally ill, meaning life expectancy of 6 months or less if the illness runs its normal course. The CHPN trap is treating “cancer,” “dementia,” or “heart failure” as automatic tickets. The ticket is the prognosis, supported by this patient’s trajectory.

Patients can and do live longer than 6 months and remain eligible if, at recertification, the physician’s clinical judgment remains that the prognosis is still 6 months or less if the disease runs its normal course. Longevity on service is not fraud by itself. Missing decline documentation is what medical review and CHPN items punish.

LCD and clinical decline: what the nurse must capture

Medicare Administrative Contractors publish Local Coverage Determinations (LCDs) that describe hospice coverage guidance for common terminal conditions. LCDs are not statutes, but they are the documentation language reviewers use. Across disease-specific LCDs, reviewers look for measurable decline, not adjectives (“appears weaker”).

Document, with dates and compared-to-last-period values:

• Palliative Performance Scale (PPS) drop (for example, 50% to 40%) and why (reduced ambulation, intake, or consciousness)
• Weight loss and reduced oral intake; mid-arm circumference or BMI when weights are unavailable
• Albumin decline when labs exist — not as a standalone eligibility test, but as supporting data
• Recurrent infections (aspiration pneumonia, urinary tract infection, sepsis) and increasing antibiotic courses or hospitalizations
• ADL decline: new dependence in bathing, dressing, transferring, feeding, continence
• Disease-specific markers when they apply (FAST stage in dementia, NYHA class and ejection fraction in heart failure, FEV1 and oxygen use in lung disease, progressive metastatic burden in cancer)

The medical director’s narrative must be patient-specific. Copy-forward “continued decline, PPS 40%” for six periods with no changing facts is a recertification failure waiting to happen. The nurse’s job is to feed the certifying physician a record that shows what changed.

Admission is not complete because a referral arrived. § 418.25 requires the hospice to obtain the necessary clinical information and to make an admission decision based on the IDG’s assessment that the patient is appropriate for hospice. The CHPN still owns the 48-hour RN initial assessment and the 5-day comprehensive assessment clocks from § 418.54 once election is complete.

Benefit periods: 90 / 90 / then 60s forever

§ 418.21 is memorization material:

1. An initial 90-day period
2. A subsequent 90-day period
3. An unlimited number of subsequent 60-day periods

The periods are available in that order and may be elected separately at different times. One election can continue across periods without a break if the patient remains in the hospice’s care, does not revoke, and is not discharged. Recertification is still required each period. Recertifications may be completed no more than 15 calendar days before the next period starts.

Exam trap: The structure is not unlimited 90-day periods, not 60/60 then 90s, and not a single 180-day benefit. After two 90-day periods, every later period is 60 days, and each of those 60-day recertifications needs a face-to-face encounter.

Face-to-face before the third period — and every period after

§ 418.22(a)(4) is among the most tested hospice payment rules on CHPN:

• Required when the patient’s total stay across all hospices is anticipated to reach the third benefit period
• Performed by a hospice physician or hospice nurse practitioner — not a physician assistant, not the attending NP who is not a hospice NP, not a social worker with a countersignature
• Occurs prior to, but no more than 30 calendar days prior to, the third-period recertification, and every benefit period recertification thereafter
• Purpose: gather clinical findings to determine continued eligibility

The clinician who performs the encounter must attest in writing, with date and signature. If a nurse practitioner or a non-certifying hospice physician performs it, the attestation must state that the clinical findings were provided to the certifying physician. The narrative for the third period and later must explain why the face-to-face findings support a 6-month prognosis.

CMS has used telecommunications flexibility for recertification-only face-to-face encounters during specified federal periods. Do not let a CHPN item about who may perform the encounter get lost in telehealth trivia. The personnel rule remains hospice physician or hospice nurse practitioner.

Live discharge, revocation, and transfer

Not every end of service is a death. CHPN groups these as live discharge scenarios, then the regulation splits the paperwork:

§ 418.26 — hospice-initiated discharge is allowed only if:

1. The patient moves out of the service area or transfers to another hospice
2. The hospice determines the patient is no longer terminally ill (improved / stabilized so a 6-month prognosis no longer holds)
3. Discharge for cause after a required process: advise the patient, make a serious effort to resolve the problem, confirm the discharge is not because the patient is using necessary hospice services, and document efforts. Behavior of other persons in the home can trigger this pathway when it seriously impairs care.

Before any § 418.26 discharge, the hospice must obtain a written discharge order from the medical director and should consult the attending physician. Discharge planning must anticipate that some patients will stabilize. When the reason is “no longer terminally ill,” plan family counseling, education, and follow-up before the discharge date. File a notice of termination/revocation with the Medicare contractor within 5 calendar days unless a final claim is already filed.

§ 418.28 — revocation is the patient’s or representative’s choice. It requires a signed statement with the effective date. The individual forfeits remaining days in that benefit period and resumes ordinary Medicare coverage of previously waived services. The person may re-elect later for any period still available if still eligible — they do not get the leftover days of the revoked period back.

§ 418.30 — change of designated hospice (transfer) is a signed statement identifying the new hospice and the date. Transfer is not a revocation.

After discharge for reasons other than immediate transfer, Medicare hospice coverage ends, waived benefits resume, and the person may elect again if eligible. CHPN items often ask what the nurse does: coordinate a safe handoff, restore community providers, and avoid framing improvement discharge as abandonment.

Related versus unrelated diagnoses for billing

Election waives Medicare payment for care related to the terminal condition and related conditions, except services by the designated hospice (or arranged by it) and services by the attending physician who is not a hospice employee and is not paid by the hospice. Unrelated items are supposed to be exceptional and unusual. The hospice should be providing virtually all needed care.

When the hospice determines conditions, items, services, or drugs are unrelated, the election statement addendum — titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” — lists them with a plain-language clinical explanation, references to relevant guidelines, and BFCC-QIO advocacy rights. If requested in the first 5 days of election, furnish the addendum within 5 days of the request; if requested later, within 3 days. Signing the addendum acknowledges receipt, not agreement.

Relatedness is a clinical judgment, not a billing convenience. Pneumonia, dyspnea workups, and opioids in metastatic lung cancer are typically related. Decubitus care in a bedbound patient with progressive neurologic disease is typically related. An unrelated determination needs a real clinical story (for example, longstanding glaucoma drops with no connection to the terminal trajectory). CHPN will punish using “unrelated” to keep a profitable service off the hospice ledger.

CHPN scenario: recertification week

A patient with mixed dementia and heart failure is on day 85 of the second 90-day period. PPS has fallen from 50% to 30%, weight is down 8 pounds, albumin is 2.6 g/dL, and there have been two aspiration pneumonias. The correct sequence is: schedule the face-to-face now (this stay will hit the third period), gather decline facts for a patient-specific narrative, obtain hospice-physician recertification no more than 15 days before the 60-day period starts, and keep related infection and heart-failure symptom care on the hospice plan — not on a phantom Part B claim.