Hospice Certification of Terminal Illness (CTI) Audit Checklist: Narrative, Physician Signature, and Timeliness

The certification of terminal illness (CTI) is the foundation of every hospice claim. Without a valid, timely certification signed by the right physicians, Medicare will not pay for hospice care, no matter how strong the clinical record is. CTI errors are also among the easiest for reviewers to find: a missing signature, a date outside the allowed window, a narrative in the wrong place, or a missing attestation can lead to denial of an entire benefit period.

Hospices face heightened scrutiny in 2026, including a nationwide enrollment moratorium, large-scale payment suspensions in Los Angeles County, CMS's new Service and Spending Variation Index, and new telehealth face-to-face limits and claims reporting requirements. In this environment, technical CTI compliance is essential.

This article explains the CTI requirements under 42 CFR 418.22, the common errors reviewers find, and a detailed audit checklist hospices can use for pre-billing reviews and internal audits. It is educational and does not replace legal or professional advice.

The Legal Requirements

Certification for Each Benefit Period

Under 42 CFR 418.22(a)(1), the hospice must obtain written certification of terminal illness for each benefit period, even if a single election continues in effect for an unlimited number of periods. Benefit periods are two 90-day periods followed by unlimited 60-day periods, under 42 CFR 418.21.

Timing

Under 42 CFR 418.22(a)(2) and (3):

• The hospice must obtain the written certification before it submits a claim for payment.

• If the hospice cannot obtain the written certification within two calendar days after a period begins, it must obtain an oral certification within two calendar days and the written certification before billing.

• Certifications may be completed no more than 15 calendar days before the effective date of election.

• Recertifications may be completed no more than 15 calendar days before the start of the subsequent benefit period.

Who Must Certify

Under 42 CFR 418.22(c):

• For the initial 90-day period, the hospice must obtain written certification, and oral certification if required, from both the hospice medical director, a physician designee, or a physician member of the interdisciplinary group, and the individual's attending physician, if the individual has one. The attending physician must meet the regulatory definition of a physician.

• For subsequent periods, certification by the hospice medical director, physician designee, or physician member of the interdisciplinary group is sufficient.

Nurse practitioners may serve as attending physicians in some respects, but they may not certify or recertify terminal illness.

Content

Under 42 CFR 418.22(b):

• The certification must specify that the individual's prognosis is for a life expectancy of six months or less if the terminal illness runs its normal course.

• Clinical information and other documentation supporting the prognosis must accompany the certification and be filed in the medical record. It may initially be provided verbally and later documented.

• The certifying physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of six months or less.

• If the narrative is part of the certification or recertification form, it must be located immediately prior to the physician's signature. If it is an addendum, the physician must also sign immediately following the narrative.

• The narrative must include a statement directly above the physician's signature attesting that by signing, the physician confirms that he or she composed the narrative based on review of the patient's medical record or, if applicable, examination of the patient.

• The narrative must reflect the patient's individual clinical circumstances and cannot contain check boxes or standard language used for all patients.

• For the third and later benefit periods, the narrative must include an explanation of why the clinical findings of the face-to-face encounter support a life expectancy of six months or less.

• The face-to-face attestation requirements in the regulation must be met.

• All certifications and recertifications must be signed and dated by the physicians and must include the benefit period dates to which they apply.

Records

Under 42 CFR 418.22(d), the hospice must make an appropriate entry in the patient's medical record as soon as it receives an oral certification, and must file written certifications in the medical record.

Admission Requirements

Under 42 CFR 418.25, the hospice admits a patient only on the recommendation of the medical director, physician designee, or physician member of the interdisciplinary group, in consultation with or with input from the attending physician, if any. In reaching a decision to certify, the physician must consider the principal diagnosis, other health conditions, and current clinically relevant information supporting all diagnoses.

The Face-to-Face Attestation

For the third benefit period and later, under 42 CFR 418.22(a)(4) and (b)(4):

• A hospice physician or hospice nurse practitioner must have a face-to-face encounter no more than 30 calendar days before the recertification.

• The person who performs the encounter must attest in writing that the encounter occurred, including the date of the visit, with signature and signature date.

• If a nurse practitioner or a physician other than the certifying physician performs the encounter, the attestation must state that the clinical findings were provided to the certifying physician for use in determining continued eligibility.

• Through December 31, 2027, the encounter may occur via telecommunications technology for the sole purpose of recertification, subject to statutory limits. For encounters on or after January 1, 2027, hospices must report telehealth encounters on the claim.

Physician Enrollment

Physicians who certify hospice eligibility must meet Medicare enrollment requirements, including being enrolled or validly opted out. Telehealth face-to-face encounters may not be performed by practitioners who are not enrolled or validly opted out. Hospices should verify enrollment status of every certifying physician, attending physician, and practitioner performing face-to-face encounters.

Common CTI Errors

Signature and Source Errors

• Initial certification missing the hospice physician's signature or the attending physician's signature, when there is an attending physician.

• Recertification signed by someone not authorized, such as a nurse practitioner.

• Missing signature dates.

• Illegible signatures without a signature log or attestation.

• Stamped signatures.

Timing Errors

• Certification signed more than 15 days before the effective date or start of the benefit period.

• Written certification signed after the claim was submitted.

• Oral certification not obtained within two days when written certification was late.

• Oral certification not documented in the record.

Narrative Errors

• Missing narrative.

• Narrative not located immediately before the signature, or addendum not signed after the narrative.

• Missing attestation statement above the signature.

• Narrative written by someone other than the certifying physician.

• Generic, templated, or copied narrative language.

• Narrative for the third or later period does not address face-to-face findings.

Face-to-Face Errors

• Encounter outside the 30-day window.

• Encounter performed by an ineligible practitioner.

• Missing or incomplete attestation.

• Missing statement that findings were provided to the certifying physician.

• Telehealth used when not permitted.

Content Errors

• Missing benefit period dates.

• Missing statement of six-month prognosis.

• Clinical documentation not filed with the certification.

The CTI Audit Checklist

Initial Certification

• Is there a written certification for the initial 90-day period?

• Is it signed and dated by the hospice medical director, physician designee, or physician member of the interdisciplinary group?

• Is it signed and dated by the attending physician, if one was designated?

• Was it completed no more than 15 calendar days before the effective date of election?

• If written certification was not obtained within two calendar days, was an oral certification obtained within two days and documented?

• Was the written certification obtained before the claim was submitted?

• Does it state the six-month prognosis?

• Does it include the benefit period dates?

• Is there a narrative composed by the certifying physician, located immediately before the signature or in a signed addendum?

• Is the attestation statement directly above the signature?

• Is the narrative individualized, without check boxes or standard language?

• Is supporting clinical documentation in the record?

• Was admission recommended by the appropriate hospice physician with attending physician input?

Second Benefit Period Recertification

• Is the recertification signed and dated by the hospice medical director, physician designee, or physician member of the interdisciplinary group?

• Was it completed no more than 15 days before the start of the period and before billing?

• Does it include the benefit period dates and six-month prognosis?

• Is the narrative present, correctly placed, attested, and individualized?

Third and Later Benefit Period Recertifications

• All items for the second benefit period, plus:

• Did a hospice physician or hospice nurse practitioner conduct a face-to-face encounter no more than 30 calendar days before the recertification?

• Is there a signed and dated attestation of the encounter, including the visit date?

• If performed by a nurse practitioner or non-certifying physician, does the attestation state that findings were provided to the certifying physician?

• If telehealth was used, was it permitted, and will it be reported on claims for encounters on or after January 1, 2027?

• Does the narrative explain why the face-to-face findings support a six-month prognosis?

Physician Status

• Are all certifying physicians and practitioners enrolled in Medicare or validly opted out?

• Are any physicians excluded or sanctioned?

Signatures

• Are signatures handwritten or valid electronic signatures?

• Are illegible signatures supported by a signature log or attestation?

• Are all signatures dated?

Electronic Signatures and EHR Design

• Make sure the EHR places the narrative immediately before the signature, with the attestation language directly above it.

• Prevent the EHR from pre-populating narrative text.

• Capture signature dates automatically and display them on printed records.

• Lock signed certifications to prevent later changes.

• Keep audit trails showing when documents were created, edited, and signed.

Writing a Compliant Narrative

The narrative must be the physician's own. Hospices can support physicians without writing for them.

• Give physicians a summary of recent measurable indicators, such as weights, intake, functional scales, and complications.

• Highlight changes since the last benefit period.

• Include face-to-face findings for third and later periods.

• Let the physician compose the narrative based on this information and the record.

• Never pre-populate narrative text or use the same language for all patients.

Example, for illustration only: "Mr. B has end-stage COPD with oxygen dependence at 4 liters, dyspnea at rest, and two hospitalizations for exacerbations in the past three months. His weight has fallen from 152 to 141 pounds over 60 days, and his PPS has declined from 50 to 40 percent. At the face-to-face encounter on June 2, the hospice nurse practitioner documented a resting respiratory rate of 28, oxygen saturation of 87 percent on oxygen, and inability to complete a sentence without pausing. These findings show progression of his lung disease and support a life expectancy of six months or less."

Physician Responsibilities

• Review the clinical record or examine the patient before signing.

• Compose the narrative personally.

• Sign and date each certification within the allowed windows.

• Review face-to-face findings for third and later periods.

• Consider discharge when the patient no longer meets eligibility.

Attending Physician Signatures

For the initial certification, the attending physician's signature is required if the patient has designated one. Common problems include:

• Delays in obtaining signatures from community physicians.

• Attending physicians who are not enrolled in Medicare or validly opted out.

• Confusion when the patient's designated attending physician changes.

Hospices should send certification documents promptly, follow up systematically, confirm enrollment status, and document attending physician changes with signed statements.

Recertifications for Transfers and Readmissions

• When a patient transfers from another hospice, the benefit period continues, and the receiving hospice should obtain the prior hospice's certifications and face-to-face documentation and complete its own certification as required.

• When a patient is readmitted after a live discharge or revocation, a new election and certification are required, and the benefit period depends on the patient's history.

• When a patient enters the third or later benefit period, confirm whether a face-to-face encounter is required before recertification.

Tracking and Workflow

• Track every patient's benefit periods, recertification due dates, and face-to-face windows.

• Send recertification packets to physicians early enough to allow review and signature within the window.

• Provide physicians with a clinical summary of measurable indicators and changes.

• Hold claims until certifications are complete and signed.

• Escalate missing signatures before the period begins.

Pre-Billing CTI Review

• Review every certification and recertification before the claim is submitted.

• Use the checklist above.

• Correct problems that can be corrected, such as obtaining a missing signature within the allowed rules.

• Do not backdate signatures or alter documents.

• Hold claims that cannot be supported.

Internal CTI Audits

• Audit a sample of certifications each quarter, including initial certifications, second period recertifications, and third and later period recertifications.

• Track error rates by element and physician.

• Provide education and feedback to physicians.

• Evaluate overpayment obligations under 42 CFR 401.305 when audits find claims paid without valid certifications.

A Hypothetical Example

A hospice audits 30 recertifications and finds that eight narratives were entered by nurses and signed by physicians, five used nearly identical language, and three face-to-face attestations performed by nurse practitioners did not state that findings were provided to the certifying physician. It also finds two initial certifications missing the attending physician's signature.

The hospice changes its EHR so the narrative field is completed only by the certifying physician, removes pre-populated text, adds a required statement to the face-to-face attestation template, and adds a pre-billing check for attending physician signatures. It retrains physicians and nurse practitioners and evaluates overpayments for affected periods with counsel. A follow-up audit three months later shows significant improvement.

Responding to CTI Denials

• Identify the specific CTI element cited.

• Locate the certification, narrative, attestation, and face-to-face documentation in the record.

• Confirm signature and date placement and timing.

• If documentation existed but was not submitted, submit it on appeal by the reconsideration level.

• If the error is real, correct the process and evaluate related claims.

Roles and Responsibilities

• Admissions staff confirm the attending physician and obtain the initial certification.

• Medical records staff track signatures and due dates.

• Physicians compose narratives and sign within windows.

• Nurse practitioners and physicians complete face-to-face encounters and attestations.

• Billing staff hold claims until certifications are complete.

• Compliance audits certifications and reports results.

Questions to Ask on Every Certification

• Would a reviewer see the right physicians' signatures, with dates inside the allowed windows?

• Is the narrative clearly the physician's own and specific to this patient?

• Is the attestation directly above the signature?

• For third and later periods, are the face-to-face date, attestation, and findings all documented?

• Are the benefit period dates on the certification?

• Was the certification complete before the claim was billed?

Common Myths

• "A strong clinical record makes up for a late signature." It does not; certification timing is a condition of payment.

• "A nurse can draft the narrative if the physician signs it." The narrative must be composed by the physician.

Electronic Signature Pitfalls

• Signature dates captured as the print date rather than the actual signing date.

• Batch signing that makes narratives look templated.

• Signatures applied by staff using a physician's credentials, which is never acceptable.

Key Takeaways

• Every benefit period needs a timely written certification signed by the right physicians.

• Certifications can be signed no more than 15 days early and must be completed before billing.

• The narrative must be composed by the physician, individualized, and placed and attested correctly.

• Third and later periods require a timely face-to-face encounter with a complete attestation.

• Pre-billing CTI review prevents most technical denials.

Frequently Asked Questions

How early can a certification be signed?

No more than 15 calendar days before the effective date of election or the start of the subsequent benefit period.

What if the written certification is late?

The hospice must obtain an oral certification within two calendar days after the period begins and the written certification before billing.

Who signs the initial certification?

The hospice medical director, a physician designee, or a physician member of the interdisciplinary group, and the attending physician if there is one.

Where must the narrative be located?

Immediately before the physician's signature on the certification, or in an addendum signed by the physician immediately following the narrative, with an attestation statement directly above the signature.

Can a nurse practitioner sign the recertification?

No. Nurse practitioners may perform the face-to-face encounter but may not certify or recertify terminal illness.

Conclusion

CTI compliance depends on details: the right physicians, signing within the right windows, a properly placed and attested narrative written by the physician, a timely and attested face-to-face encounter for third and later periods, and benefit period dates on every certification. Hospices that track deadlines, design EHR workflows around the regulation, conduct pre-billing reviews, and audit certifications regularly can prevent technical denials and protect every benefit period.

How HealthBridge Can Help

HealthBridge is a healthcare management consulting firm that helps hospices strengthen CTI compliance through certification audits, EHR workflow reviews, recertification tracking systems, physician education, and pre-billing review programs. If you want your certifications to stand up to audit, please get in touch with us. We will be happy to help you with this topic.

References

• Electronic Code of Federal Regulations. 42 CFR Part 418, Subpart B (including 418.21, 418.22, 418.25). https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-B

• Electronic Code of Federal Regulations. 42 CFR 401.305, Requirements for Reporting and Returning of Overpayments. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-A/part-401/subpart-D/section-401.305

• Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 9, Coverage of Hospice Services Under Hospital Insurance. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c09.pdf

• Centers for Medicare & Medicaid Services. Medicare Program Integrity Manual, Chapter 3 (Signature Requirements). https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/pim83c03.pdf

• Federal Register. Medicare Program; FY 2027 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Program Requirements (August 3, 2026). https://www.federalregister.gov/documents/2026/08/03/2026-15686/medicare-program-fy-2027-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting

• Centers for Medicare & Medicaid Services. Hospice News and Announcements. https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers/information-centers/hospices/news-announcements

• Centers for Medicare & Medicaid Services. Home Health and Hospice Nationwide Moratorium Q&As. https://www.cms.gov/files/document/hh-hospice-moratorium-faqs.pdf

• U.S. Social Security Administration. Social Security Act, Section 1814(a)(7). https://www.ssa.gov/OP_Home/ssact/title18/1814.htm