CMS reminded hospices recently about the need to comply with Medicare hospice election statements and certification of terminal illness (CTI) requirements. This reminder comes shortly after CMS’ announcement of the expansion of the targeted probe and educate (TPE) method of medical review to hospices and other provider types (see HPS coverage of TPE here and here.) We believe there is a strong possibility that CMS will conduct a TPE review of hospice election statements and certifications of terminal illness. The reminder comes, in part, in the form of a re-release of two MLNMatters articles, SE 1628 and SE 1631. CMS also directed individuals to a 2016 Office of the Inspector General (OIG) report and the CMS Hospice Payment Systems booklet.

Now is the time for hospices to carefully review their Medicare election statements and CTIs and make any necessary corrections. Even if hospices have had recent Medicare certification/recertification surveys without deficiencies related to the election statement or CTI, the hospice should not assume that its documents meet all technical requirements. This is because surveyors typically have not assessed compliance with these documents as part of every survey. However, this could be changing. One of the recommendations from the OIG in its 2016 report is for CMS to instruct surveyors to strengthen their review of election statements and certifications of terminal illness. We believe surveyors would assess compliance with the content of the election statement utilizing 418.104(a)(2) found at L673 of the CMS State Operations Manual, Appendix M which states:

§418.104(a)(2) Signed copies of the notice of patient rights in accordance with §418.52 and election statement in accordance with §418.24.

Section 418.24 states:
Content of election statement. The election statement must include the following:
(1) Identification of the particular hospice and of the attending physician that will provide care to the individual. The individual or representative must acknowledge that the identified attending physician was his or her choice.
(2) The individual’s or representative’s acknowledgement that he or she has been given a full understanding of the palliative rather than curative nature of hospice care, as it relates to the individual’s terminal illness.
(3) Acknowledgement that certain Medicare services, as set forth in paragraph (d) of this section, are waived by the election.
(4) The effective date of the election, which may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement.
(5) The signature of the individual or representative.

(d)Waiver of other benefits. For the duration of an election of hospice care, an individual waives all rights to Medicarepayments for the following services:
(1) Hospice care provided by a hospice other than the hospice designated by the individual (unless provided under arrangements made by the designated hospice).
(2) Any Medicare services that are related to the treatment of the terminal condition for which hospice care was elected or a related condition or that are equivalent to hospice care except for services –
(i) Provided by the designated hospice:
(ii) Provided by another hospice under arrangements made by the designated hospice; and
(iii) Provided by the individual’s attending physician if that physician is not an employee of the designated hospice or receiving compensation from the hospice for those services.

We believe surveyors would assess compliance with the CTI utilizing 418.102(b) found at L667 of the CMS State Operations Manual, Appendix M which states:

§418.102(b) Standard: Initial certification of terminal illness.

The medical director or physician designee reviews the clinical information for each hospice patient and provides written certification that it is anticipated that the patient’s life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination:

  1. The primary terminal condition;
  2. Related diagnosis(es), if any;
  3. Current subjective and objective medical findings;
  4. Current medication and treatment orders;
  5. Information about the medical management of any of the patient’s conditions unrelated to the terminal illness.

Hospices should ensure that the medical director or physician designee is reviewing the information listed in L667 and this is clear in the patient’s medical record. The State Operations Manual instructs surveyors to look for the four items above in the patient’s medical record.

Additional specifics of what is required in the CTI is found in the Medicare Benefit Policy Manual, Chapter 9, Section 20.1.

HPS Alliance Members can now access two new Hospice audit tools, as part of their membership. The Hospice Medicare CTI Audit Tool allows Hospice providers to audit the certification of terminal illness for all technical requirements. The Hospice Medicare Election Audit Tool allows Hospice providers to audit the Medicare election statement for all technical requirements.

Click here to download the tool from your Alliance member dashboard. If you would like access to this tool along with all of our Alliance member resources click here to learn more.