CTI Writing Best Practices for Hospice Agencies in California

Introduction

Certification of Terminal Illness (CTI) is a vital part of hospice eligibility and billing compliance. For Medicare to approve claims, hospice providers must adhere to detailed documentation rules regarding the timing, format, and content of these certifications. Inaccuracies or omissions can lead to claim denials, delayed payments, or citations during audits.

This guide outlines best practices for hospice agencies in writing and managing CTI documentation—from when to obtain it, to who can sign, and what must be included.

Timing Requirements: Certification & Recertification

For every hospice benefit period—whether the initial admission or a subsequent renewal—CTIs must be timely:

• Initial certifications can be completed up to 15 days before the patient elects the hospice benefit.

• Recertifications for ongoing benefit periods may also be completed up to 15 days in advance.

• Regardless of early preparation, verbal or written certification must be received no later than 2 calendar days (by the end of Day 3) after hospice care officially begins.

If written documentation isn't ready within this timeframe, verbal confirmation from the appropriate physician must be obtained. It's essential that hospices define, in accordance with local and state regulations, which staff members are authorized to accept these verbal certifications.

Pro Tip: A claim cannot be submitted to Medicare unless the written CTI is complete, signed, and dated. Submitting prematurely may result in denial or payment delays.

Required Content in the CTI

The CTI must reflect the clinical judgment of the hospice’s physician team. This includes the hospice medical director or a physician member of the interdisciplinary group (IDG), and—if applicable—the patient’s attending physician. Nurse practitioners and physician assistants are not allowed to certify or recertify patients as terminally ill. If the attending provider is an NP or PA, the hospice physician must complete the certification independently.

Each CTI (initial and subsequent) must include:

• A prognostic statement confirming the patient is expected to live six months or less, assuming the illness follows its usual course.

• A physician-written narrative explaining the specific clinical facts that support the terminal prognosis. This summary must:

  • Be composed only by the certifying physician

  • Appear immediately above the signature on the form if included within the certification

  • Be separately signed if submitted as a standalone addendum

• A statement of attestation affirming the narrative was personally written by the physician after reviewing the patient's medical records or conducting an examination.

• The specific dates covered by the benefit period.

Note: Standardized templates, checkboxes, or generic language should not be used. Each narrative must be individualized.

Face-to-Face Encounter Documentation

Starting from the third benefit period, Medicare requires additional evidence to support ongoing hospice eligibility. This includes:

• Documentation of a face-to-face encounter

• The date of the encounter

• An attestation statement by the physician or nurse practitioner confirming that the visit took place

• If conducted by an NP, a note that their findings were communicated directly to the certifying physician

The narrative for these recertifications must explain how the encounter supports the continued prognosis of six months or less.

Physician Signatures: What’s Required?

Initial Certification (First Benefit Period):

Must be signed and dated by:

• The hospice medical director (or a physician member of the IDG)

• The attending physician, if one has been designated by the patient

📌 The attending physician must be a licensed MD or DO, and recognized by the patient as the primary provider responsible for their medical care at the time hospice services begin.

Recertifications (Subsequent Periods):

Only the hospice physician (either the medical director or IDG physician) is required to sign and date the form. The attending physician’s signature is not needed beyond the initial certification.

Common CTI Errors to Avoid

Failure to meet Medicare’s CTI requirements can result in rejected claims or audit findings. Common documentation issues include:

• Signing the CTI before the official start of the benefit period

• Missing required signatures for the initial certification (especially from both physicians)

• Omission of the physician-written narrative

• Missing or incomplete attestation statements

• Verbal certification not documented when written confirmation was delayed

• Illegible or undated physician signatures

• Certification forms lacking the specific benefit period dates

Staying Compliant

Hospice providers must remain vigilant in ensuring CTIs are thorough, timely, and properly documented. Every element—clinical narrative, physician signatures, and date accuracy—plays a role in safeguarding both patient care and financial viability.

At SummitRige, we help hospice agencies maintain CTI compliance through policy audits, chart review tools, and tailored submission support. Whether you're refining your internal processes or responding to regulatory scrutiny, our experts ensure your certifications meet state and federal expectations.