Wiki "Valid" Physician Orders

[lverellen]

Does anyone have documentation regarding a specific format, form, or documentation requirements (other than signature, date and time for all services ordered) for physician orders. We have a concern regarding the fact that we have a group of providers who are not using any particular format, nor are they stating in a progress note or "order" sheet that they are ordering tests/injections/infusions/labs. I need something in wrtting specifically stating the format that is to be used.
THX!
L

 

[mdoyle53]

How about "Medical Necessity". There needs to be a reason for ordering tests, etc. These should be documented in the chart to show there is a medical necessity for the order. Medicare has begun to take money back for the lack of medical necessity in the note.

 

[rthames052006]

How about "Medical Necessity". There needs to be a reason for ordering tests, etc. These should be documented in the chart to show there is a medical necessity for the order. Medicare has begun to take money back for the lack of medical necessity in the note.

To feed off Michael's comment above, if you take a look at the CERT reports from your MAC you should see that orders and medical necessity are both errors that are being found for labs and other tests that are billed for but upon review from the CERT there is no order on file nor is med necessity established for the service(s) provided.

I use this as a training tool for my providers during internal audits.