Six-Month Prognosis Documentation

Six-month prognosis documentation is the physician certification, plus the supporting clinical evidence, establishing that a hospice patient's life expectancy is six months or less if the terminal illness runs its normal course. It is the eligibility foundation of the Medicare hospice benefit and must be re-established for every benefit period under 42 CFR 418.22 ^[1].

The certification of terminal illness (CTI) must state that the individual's prognosis is a life expectancy of six months or less if the illness runs its normal course (42 CFR 418.22(b), https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-B/section-418.22). For the initial 90-day period, certification is required from both the hospice medical director (or the physician designee or physician member of the interdisciplinary group) and the patient's attending physician, if the patient has one; recertifications for later periods require only a hospice physician (42 CFR 418.22(c)). The certifying physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of six months or less, and when the narrative is part of the certification form it must be located immediately before the physician's signature (42 CFR 418.22(b)(3), https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-B/section-418.22). Written certification must be on file before the hospice bills; if it cannot be obtained within two calendar days after a period begins, the hospice must obtain oral certification within those two days and the written certification before submitting the claim (42 CFR 418.22(a), https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-B/section-418.22). Clinical information supporting the prognosis may initially be provided verbally but must be documented in the medical record and filed with the written certification.

The six-month prognosis is the single most-scrutinized element in hospice medical review. Long-length-of-stay claims drawn by Targeted Probe and Educate (TPE), UPIC, RAC, and SMRC contractors are routinely denied when the narrative is boilerplate that could describe any patient rather than this patient's specific, documented decline. A denial does not cost one visit; it recoups the entire episode, and eligibility not supported by the record is a common theory in False Claims Act settlements. A defensible certification narrative ties disease-specific clinical findings (weight loss, functional decline, comorbidities, PPS/FAST scores) to the six-month trajectory and is authored by the physician rather than generated from a template. Because certification repeats at every benefit period, a weak process compounds across a long stay.