Background: Hospice in the United States is comfort-focused care delivered by an interdisciplinary group meant to address the holistic needs for a patient with terminal illness (1-4).  Under the Medicare Hospice Benefit (MHB), the Centers for Medicare and Medicaid Services defines terminal illness as “a medical prognosis of 6 months or less if the illness runs its normal course” (2,3, Fast Fact #82).  Hospice physicians, including the hospice medical director or physician member of the interdisciplinary group, certify a patient as terminally ill by completing and signing a certification of terminal illness (CTI), which includes a signed physician narrative documenting the clinical basis for a terminal prognosis (2,3).  In 2011, CMS implemented a MHB requirement for face-to-face encounters (FTFE).  A FTFE involves a physician or nurse practitioner evaluating the patient to obtain clinical evidence for the certifying hospice physician to determine ongoing prognosis (2-6). Hospice care under commercial insurance may have different requirements. This Fast Fact reviews indications and requirements for the FTFE under the MHB, how the non-hospice clinician can support the FTFE, and domains to consider during the FTFE.

FTFE indications and timing: The MHB divides hospice coverage into benefit periods (BPs).  The 1st and 2nd BPs are 90-days each for a total of 6 months.  All subsequent BPs are 60 days (2-4).  A FTFE must occur no earlier than 30 days before and no later than the first day of the 3rd and each subsequent BP (barring exceptional circumstances) (2,3,7,8).  If a FTFE is not completed within this timeframe, CMS expects hospice to discharge the patient from the MHB but continue to care for the patient on the hospice’s own expense until the FTFE occurs (3). Patients re-enrolling in the 3rd or subsequent BP after a “live hospice discharge” will need a FTFE before restarting hospice care (8, Fast Fact # 521).

FTFE purpose and requirements: The FTFE’s purpose is to provide clinical evidence to help the certifying hospice physician determine if a patient coming onto the 3rd or later benefit period continues to have a prognosis of 6 months or less. The encounter can be in-person or via telehealth by a hospice-employed or contracted physician, or a hospice-employed nurse practitioner (7,8). The certifying hospice physician must utilize the FTFE clinical findings when writing their CTI narrative. If clinical evidence no longer supports a terminal prognosis of 6 months or less, the hospice team must initiate a “live hospice discharge,” even for patients with high disease burden or frailty (8, Fast Fact # 521).

Supporting the FTFE as a non-hospice clinician: While only hospice clinicians performing the F2F encounter can document a F2F visit note, non-hospice clinicians (e.g., PCPs, specialists, skilled nursing facility staff) can provide impactful longitudinal data or clinical observations to the hospice team that identify or document specific quantitative and/or qualitative decline between two time points (5,8,9).. Illustrative examples that non-hospice clinicians can provide to hospice teams include (9): 

• Measured 10% weight loss within six months.
• Time to task for eating one meal increased from 15 to 40 minutes over three months.
• Loss of ability to drink liquids with straw and progression to spoon-fed liquids over two months. 

Involve the Caregiver: A patient’s caregiver usually spends more time with the patient than anyone else.  They often provide valuable evidence for ongoing hospice eligibility, especially when clinicians counsel them on what to watch for. For example, a caregiver might notice that the patient is eating less or taking longer to eat the same amount of food compared to two months ago.

FTFE assessment: Consider the following domains in a FTFE (not comprehensive) (8). Only use diagnostic testing such as labs (e.g., serum albumin for nutrition, creatinine for renal function) or imaging if the benefits in prognostic formulation significantly outweigh the burden. 

• Nutrition: Quantitative (Quant): appetite (# meals/day, % of meals eaten), weight, body mass index, mid-arm or mid-thigh circumference; Qualitative (Qual): dietary consistency (was on chopped diet now pureed; was on thin liquids now thickened), physical signs of wasting (well-fitted clothes in past now loose fitting, temporal wasting, prominent clavicles, concaved abdomen).
• Function: Quant: Activities of Daily Living (ADLs), Palliative Performance Scale, Karnofsky Performance Scale (10), number of falls, time to task (e.g. time to eat one meal), ability to swallow (# throat clearing, coughs, or choking episodes per meal), angle of contracted extremities; Qual: assistive devices (e.g. used cane and now wheelchair bound), feeding (1:1 feedings, feeding refusal, pocketing, was spoon-fed and now syringe fed), presence of fecal or urinary incontinence.
• Cognition: Quant: # hours asleep per 24 hours, mini mental status, speech and communication (# words/sentence), confusion (# hours lucid vs. confused); Qual: ability to verbalize (slurred speech, whispered speech), failure to recognize familiar people, decline in complexity of daily activities (e.g. played chess, then only watched TV, now falls asleep during meals).
• Disease-specific: e.g., Alzheimer’s (FAST score), congestive heart failure (NYHA class, diuretic or O2 adjustments, edema, # exacerbations), renal failure (volume overload, signs of uremia, urine output).
• Non-specific: Recurrent infections, wounds (e.g. pressure ulcers with stage), skin appearance, vital signs, uncontrolled symptoms (e.g. pain, dyspnea), comfort medication titration, emergent events, ascites, aspiration events, prognostic indices: e.g., Mitchell Index (for nonspecific advanced dementia), Porock Index (11,12) 

After the visit: Ensure FTFE documentation is compliant with the Medicare Benefit Policy Manual (3,6).

References 

1. Medicare Hospice Benefits. Centers for Medicaid and Medicare Services.  2023.  Available from: https://www.medicare.gov/Pubs/pdf/02154-medicare-hospice-benefits.pdf. Accessed: July 4, 2026.
2. Title 42, Chapter IV, Subchapter B, Part 418.  Electronic Code of Federal Regulations.  2026.  Available from: https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418.  Accessed: July 4, 2026.
3. Chapter 9 – Coverage of Hospice Services Under Hospital Insurance.  Medicare Benefit Policy Manual.  Centers for Medicare and Medicaid Services.  2026.  Available from: https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/bp102c09.pdf.  Accessed: July 4, 2026.
4. Bhatnagar M, Kempfer LA, Lagnese KR.  Hospice Care.  [Updated 2023 Mar 13].  In: StatPearls [Internet].  Treasure Island (FL): StatPearls Publishing; 2024 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537296/.  Accessed: July 4, 2026.
5. Harrold J, Harris P, Green D, ​et al.​  Effect of the Medicare face-to-face visit requirement on hospice utilization.  J Palliat Med. 2013;16(2):163-166. doi:10.1089/jpm.2012.0349.
6. Centers for Medicare and Medicaid Services.  MLN Matters® Number: SE1628. 2016.  Available from: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se1628.pdf.   Accessed: July 4, 2026.
7. Medicare Hospice Certification and Recertification Compliance Guide.  National Alliance for Care at Home, 2021.  Available from: certification_compliance_guide.pdf Accessed: July 4, 2026.
8. Quinlin, Linda DNP.  Face-to-Face Documentation Using the FACE-2-FACE Method.  Journal of Hospice & Palliative Nursing 2019; 21(4):305-311.
9. Templeton, Lauren DO.  Hospice Physician Documentation Clinic: Physician Utilization of Hospice Assessment Tools.  Presented Online.  Weatherbee Resources.  2022 Jan.
10. Mehta A, Chai E, Berglund K, et al.  Using Admission Karnofsky Performance Status as a Guide for Palliative Care Discharge Needs.  J Palliat Med. 2021 Jun;24(6):910-913.
11. Mitchell SL, Miller SC, Teno JM, et al.  Prediction of 6-month survival of nursing home residents with advanced dementia using ADEPT vs hospice eligibility guidelines.  JAMA. 2010;304(17):1929-1935.
12. Porock D, Parker-Oliver D, Petroski GF, et al.  The MDS Mortality Risk Index: The evolution of a method for predicting 6-month mortality in nursing home residents.  BMC Res Notes. 2010;3:200. Published 2010 Jul 16.

Authors’ Affiliations: Matthew Kwong, MD:* Asian Network Pacific Home Care and Hospice, Oakland, CA; Dyman Kwarciak, MD:* Mayo Clinic, Jacksonville, FL; Robin Turner, MD: Hospice Medical Director Certification Board, Schaumburg, IL. 
*These two authors contributed equally to this work and are designated as co-first authors.
Version History: first electronically published in July 2026.  Originally edited by Sean Marks MD.
Conflicts of Interest: None to report.
Authors Attest that they did not use large language models or artificial intelligence in the writing of this Fast Fact.