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Verbal Orders at Start of Care: Problematic for Agencies

Posted on Wednesday, March 29, 2017 4:55 AM

The Issue

Obtaining initial orders at the time of referral and for continuing services at the start of care is vital to a home care organization’s preservation of revenue. Lack of documentation of physician contact is an issue we frequently observe when conducting a compliance audit. It is also an increasing reason for post payment denials on review by the MACs or other contractors. The National Association for Home Care and Hospice (NAHC) reported last year that agencies are receiving denials for not having documentation of physician contact and approval of the plan of care. Lack of documentation is also a potential non-compliance Medicare survey issue as well as a possible liability for the agency for performing services without a physician order.

The Regulations

The regulations are clear: physician orders are required prior to providing care or services. Typically the orders received at the time of referral are very minimal. For example, “PT- Evaluate and Treat” or “SN for wound care and assessment” are some of the orders frequently received from referral. Once the assessment is completed, the clinician develops the plan of care which includes specific interventions, disciplines and frequencies of services. The practice of some agencies is to put the plan of care in writing and send to the physician for signature without first contacting the physician for verbal approval of the plan and the additional orders. This does not meet the requirement that the plan of care be approved by the physician prior to initiating the services. When suggested orders are prepared and sent for physician signature without a prior contact with the physician, the orders do not take effect until they are signed. Leaving a message on the physician’s voicemail outlining planned treatment and requesting the physician call back if he/she disagrees does not constitute a valid order unless the physician calls back with an approval.

The Process

From a process standpoint, the clinician making contact with the physician should document the contact in the clinical record with the clinician’s signature and date. The clinician should also include what was reported to the physician, how the physician responded, and a general statement regarding the nature of the orders. If the POC has not yet been sent to the physician for signature, the additional orders can be added to the POC; the Verbal Start of Care (VSOC) date in locator 23 is not changed. The notation of physician contact and receipt of orders supports the inclusion of these additional orders on the POC. The notation regarding physician contact may be on the assessment, a case communication note, or other document maintained in the clinical record.

Resources

  • Medicare Benefit Policy Manual 100-02 Chapter 7 Home Health Services; Section 30.2.5 Use of oral (verbal) Orders
  • The State Operation Manual. Go to the following link: https://www.cms.gov/OASIS/10_Training.asp and select State Operations Manual. Search for “orders” for the applicable sections
  • The NAHC Report May 22, 2012 “Denials Issued Based on Failure to Confirm Plan of Care”

It is essential that an agency monitor compliance with the approved practice for obtaining and documenting orders at the start of care. With all of the new and continually changing regulations, and the increased regulatory monitoring programs, Corridor can provide mock surveys, compliance assessments and audits, accreditation preparation and training activities to ensure your agency is as prepared as possible in this ever-changing regulatory environment.

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