Hospice Tools Certification and Face-to-Face Compliance Guide

February 17, 2026

Hospice Certifications: What CMS Requires, Potential Pitfalls, and How to Stay Audit-Ready

Hospice certification rules look straightforward.

Two 90-day benefit periods.
Then 60-day periods.
Physician certification.
Face-to-face encounters later on.

Yet, certification and recertification errors remain one of the most common reasons hospice claims are denied, delayed, or recouped.

Hospice certifications sit at the intersection of:

Federal Medicare rules
State Medicaid programs
Multiple clinician roles
Tight, regulatory mandated timelines
High-risk edge cases

This article breaks down what Centers for Medicare & Medicaid Services (CMS) actually requires and common problems.

Medicare Hospice Benefit Periods Are Federal & Uniform

If a patient is receiving Medicare hospice, the benefit structure is identical in every state:

1st benefit period: 90 days
2nd benefit period: 90 days
All subsequent periods: 60 days each

That structure does not change by state.

No state — including Pennsylvania, Texas, Arizona, or California can shorten, lengthen, or redefine Medicare hospice benefit periods.

When Medicare is the payer, the timeline is always:

90 / 90 / 60 / 60 / 60…

Many compliance problems begin when agencies unknowingly apply Medicaid or internal rules to Medicare patients.

Problem: Hospice Certifications Aren’t One Thing

Most certification mistakes don’t happen because staff are careless.
They happen because different requirements sound interchangeable, but aren’t.

CMS requires three distinct things, each with different rules.

The Three Required Components

1. Physician Certification or Recertification of Terminal Illness

This is a legal attestation, not a clinical note.

It states that:

The patient has a prognosis of six months or less if the disease runs its normal course.

Key points:

Required every benefit period
Must be signed by a physician (MD or DO)
Nursing “recertifications” do not replace this
Late signatures may be allowed — but are high audit risk

2. Clinical Narrative (LCD Support)

This is the clinical evidence supporting hospice eligibility. It:

Explains why the patient is terminal
Shows decline over time
Must align with the applicable LCD or NCD

It may be written by:

RN
NP
PA
Physician

But it does not create compliance on its own. This is where copy-forwarded language, vague statements, and generic phrases often trigger denials.

3. Face-to-Face Encounter (F2F)

Face-to-face encounters are a separate requirement that begins later in the hospice stay. They are required:

1. Starting with the third benefit period

2. For every subsequent 60-day period

Critical rules:

1. Must occur within the 30 days prior to the start of the new period

2. Must be completed before physician recertification

Face-to-face encounters may be performed by:

A. MD or DO

B. NP or PA employed or contracted by the hospice

No grace period. One day outside the window invalidates the period. This is one of the most unforgiving areas of hospice compliance.

Who Can Do What

Physicians (MD/DO)
- Can certify and recertify
- Can perform face-to-face encounters
Nurse Practitioners / Physician Assistants
- Can perform face-to-face encounters (if hospice-employed or contracted)
- Cannot certify Medicare hospice
Registered Nurses
- Can document decline and write narratives
- Cannot certify or perform F2Fs

Internal nursing recerts are clinically valuable, but CMS does not recognize them as certification.

The State Rule Myth

A common belief we hear is:

“Our state does things differently.”

For Medicare hospice, that’s simply not true.

However, the confusion usually comes from Medicaid hospice, which is state-administered.

Some states:

Use 60-day certification cycles for Medicaid hospice
Require different physician review intervals
Use state-specific forms

Example: Pennsylvania

Pennsylvania’s Medicaid hospice program uses 60-day certification intervals.

That rule:

Applies only to Medicaid hospice
Does not override Medicare hospice rules
Does not change benefit periods when Medicare is the payer

Agencies that don’t clearly separate Medicare and Medicaid workflows often drift out of compliance without realizing it.

Audit Focus: Timing and Edge Cases

Surveyors and medical reviewers don’t just look at routine cases.

They look closely at:

Long lengths of stay
Dementia and non-cancer diagnoses
Patterns of late certifications
Face-to-face timing
Transfers, revocations, and discharges

Common high-risk scenarios include:

Transfers between hospices (benefit periods continue)
Revocations (benefit periods pause, then resume)
Live discharges (benefit periods end; a later admission restarts at day 1)
Hospitalizations (do not reset benefit periods)

Download the Hospice Tools Guide to Hospice Certifications

We created the Hospice Tools Certification & Face-to-Face Compliance Handbook to help hospice agencies:

understand Medicare’s 90 / 90 / 60 benefit structure
clearly distinguish certification, recertification, and face-to-face requirements
avoid common timing errors that trigger denials
navigate transfers, revocations, live discharges, and readmissions correctly
separate Medicare and Medicaid workflows safely
implement practical QA checklists to stay audit-ready