Eli's Hospice Insider

Don't let this critical bit of info get lost in the shuffle.

The federal government might not have the authority to require a standalone certification of terminal illness for your hospice patients, but getting one anyway is probably good for your bottom line.

Hospices have been confused about whether to include the physician's CTI in their plan of treatment, plan of care, or as a separate stand-alone document. Some hospices "currently combine the CTI with their hospice's [POT] that contains the patient's subjective and objective medical findings, medications, and physician treatment orders," the National Association for Home Care & Hospice notes. In other words, on "the old 485."

NAHC asked the Centers for Medicare & Medicaid Services about the dilemma and got a response that encourages the stand-alone CTI, the trade group reports. Regulations at 42 CFR Section 418.22 do not refer to the CTI as being part of any other document, CMS tells NAHC. The specific description of the POC doesn't include a CTI component, CMS adds.

Regulations no longer recognize the "plan of treatment," so CMS can't say what should or shouldn't be in it, the response continues. "It is very clear that [CMS] would like the CTI to be a stand-alone separate document in the patient's medical record," NAHC concludes. "It is also clear that the CTI cannot be part of the plan of care (POC). However, CMS falls short of stating that the CTI cannot be a part of the POT because they no longer have regulatory language that speaks to the POT."

Good idea: While CMS can't mandate a stand-alone CTI, smart hospices will use one anyway, advises attorney Mary Michal with Reinhart Boerner Van Deuren in Madison, Wis. That's because combining the CTI with other documents could be risky for your claims.

"We have seen a number of instances in which hospices have tried to combine documents (for example, the Notice of Election) with the certification of terminal illness," Michal says. "If not done in a very careful manner, the combining of forms may result in required language being left off the forms," she adds. That leaves a prime target for medical reviewers to pounce on, Michal cautions. Then hospices can run into massive technical denials. If a regional home health intermediary decides that the CTI is faulty, "this might lead to denials for every claim submitted to the RHHI under an ADR," Michal warns. That's because "the same language is likely found in all [CTI] statements."

The result: Cash flow difficulties, targeted medical review, administrative burden, and financial burden caused by unsuccessful appeals are just some of the consequences, she explains.

Beware Heightened Scrutiny "My recommendation is that it be a standalone document," agrees hospice consultant HeatherWilson with Weatherbee Resources in Hyannis, Mass. "Given the level of regulatory scrutiny hospices are experiencing now -- and likely to experience even more in the future -- the CTI is a crucial document to demonstrate patient eligibility."

"There should be no mistake where it is, that it is valid and available to reviewers," Wilson adds.

Another reason: "I'm all for streamlining documentation," says consultant Karen Vance with BKD in Springfield, Mo. But a stand-alone CTI document will also head off another common technical denial issue -- faulty dates.

For the date reason alone, "it is helpful to have separated and distinct documents," Vance believes. "Too many times, the agency's process of pulling together the POC, getting signatures, etc., bogs down the very real problem of getting the physician signatures with good dates on them." If the verbal orders are buried in the POC, and not captured in a good time frame, "it hangs up being able to get that very critical condition met," Vance warns.

However, if you think your combined CTI document stands up to the claims and compliance risks, don't let CMS pressure you into changing it, asserts attorney Deborah Randall with Arent Fox in Washington, DC. "One of the positive features of the Medicare hospice regulations is they respect each hospice's right to address the regulatory obligations in an individual manner," Randall says. "Unless CMS intends to specify form and filing requirements in regulations, CMS should not suggest how many or how few the hospice's documents should be."