CGS Clarifies CTI Questions For Hospices

Experts Answer Questions on Properly Documenting the Physician Certification of Terminal Illness in New Training

In case you missed it, a recording of the "All You Need to Know About the Physician Certification of Terminal Illness (CTI)" training is now available to view on demand.

Staff involved in documenting the CTI, including physicians, nurse practitioners (NPs), and other advanced practice registered nurses, attended the training. CGS experts answered over 50 questions live; we've compiled the most popular ones below.

To access the training, you must register and create a profile. From there, you can view all recorded sessions by going to Schedule at the top of the page and selecting On Demand in the drop-down menu.

Questions and Answers

1) We recently received information from the Centers for Medicare & Medicaid Services that telehealth face-to-face visits are acceptable until 12/31/24 and are being evaluated for future use as well. Can you please confirm?

Correct. Telehealth face-to-face visits are allowed until the end of 2024 and must include both audio and visual components.

2) If the CTI is not completed by the hospice physician team on the third day after the start of the episode, does the agency perform an administrative discharge and readmit the patient or bill with condition/occurrence code 77 for non-billable days?

Please refer to the CGS website for information on untimely certifications and occurrence span code (OSC) 77.

3) There is no diagnosis code to document when you are using non-disease-specific guidelines, correct? If a provider says the patient is eligible under the non-disease-specific guidelines, finding an ICD-10 to use as primary can be a struggle.

It's important to be very careful in the interpretation of the Hospice Local Coverage Determination (LCD). The Hospice LCD provides guidelines for making determinations about whether the patient is terminal (i.e., what to look for and what the reasonable and necessary care is for a terminal patient), which is a benefit access condition. You must have a primary or terminal diagnosis, and non-disease-specific guidelines factor into this primary or terminal diagnosis.

4) Is continuous home care available for use if a caregiver is not available to provide care (e.g., the caregiver has surgery)?

In this circumstance respite care may be a possible solution.

5) When using the LCD non-disease-specific guidelines, do you always pick the primary diagnosis as the most likely, even if the patient doesn't exactly meet the disease-specific guidelines for that diagnosis? We see this a lot when patients have a multi-diagnoses reason for qualifying.

You cannot use the non-disease-specific guidelines alone. You must have a terminal disease listed in the LCD disease-specific guidelines. If the patient has multiple diagnoses, then lean to the one that is having the most effect on the patient.

6) When a patient elects a primary care provider who is an NP, is the hospice-employed medical director CTI enough or does the NP's overseeing physician need to sign CTI?

In this circumstance, the hospice-employed medical director's signature is the only one required.

7) Are co-morbidities required on the CTI?

Although documenting co-morbidities is not required, doing so is important because it helps to identify why the patient has a terminal prognosis. We recommend that you document comorbidities as they might make the difference between a claim being paid or denied.

8) Is a physician's order required to do a start of care (SOC) assessment by the registered nurse?

A certification of terminal illness is required (written or verbal) within the 2 days of the election of hospice care, but a physician’s order is not required to be admitted or for the RN to conduct an initial assessment or begin a comprehensive assessment. Also, a certification of terminal illness is not an order. A common misunderstanding by hospices is that the certification of terminal illness is an order.

9) Is a new CTI required if a patient transfers to our hospice in the middle of a benefit period, or is the one from the previous hospice sufficient?

No, a new CTI is not required when transferring agencies.

10) Can an NP remain as the attending for the patient when they are put on hospice?

Yes, an NP can be assigned as the attending.