Documentation Updates for Physicians - sjhsyr.org · • CFR §424.13 14 . ... – As specified in 42 CFR 424.11, no specific procedures or forms are required for certification and
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AHA Solutions, Inc., a subsidiary of the American Hospital
Association, is compensated for the use of the AHA marks and for
its assistance in marketing endorsed products and services. By
agreement, pricing of endorsed products and services may not be
increased by the providers to reflect fees paid to the AHA.
Physician Orders
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• For payment of hospital inpatient services under
Medicare Part A, the order must specify the
admitting practitioner’s recommendation to admit
“to inpatient,” “as an inpatient,” “for inpatient
services,” or similar language specifying his or
her recommendation for inpatient care
Page 50942, IPPS
• “Admit to Tower 7” or “Admit to Dr. Smith” are
not recommended
Physician Order
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Some commenters commented that their current processes provide for admission “to case management” or “to utilization
review” rather than specifying inpatient admission.
Response: “As we discussed above, many public comments from physicians indicated that they believed the physician should be involved in the determination of patient status, and we agree. To reinforce this policy and reduce confusion among hospitals, beneficiaries, and physicians on the differences between outpatient observation and inpatient services, we are providing in this final rule that the order for inpatient admission must specify admission “to or as an inpatient.”
Page 50942, IPPS
Physician must be involved in
Order Determination
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Physician Order Clarification
• Qualifications of the ordering/admitting practitioner: – At some hospitals, practitioners who lack the authority to admit inpatients under either
State laws or hospital by‐laws may nonetheless frequently write the sets of admitting orders that define the initial inpatient care of the patient. In these cases, the ordering practitioner need not separately record the order to admit ….. the order must identify the qualified “ordering practitioner”, and must be authenticated by the ordering practitioner (or by another practitioner with the required admitting qualifications) prior to discharge.
• Verbal orders: – A verbal or telephone inpatient admission order must be authenticated (signed, dated
and timed) by the ordering practitioner (or by another practitioner with the required admitting qualifications in his or her own right) in the medical record prior to discharge, unless the hospital or the State requires an earlier timeframe
• Timing: – The order must be furnished at or before the time of the inpatient admission.
Sept 5 CMS Update Memo
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• Inpatient Cases: must include the words “Admit” and
“Inpatient” to be a valid inpatient order
• Observation/Outpatient Cases: Should include the phrase
“refer for Observation Services” or “outpatient status”
– Avoid using “admit” and “Observation or Outpatient” in the same
order. CMS considers this to be contradictory
– “Admit to Tower 7” or “Admit to Dr. Smith” are not recommended