Coding, Classification & Reimbursement

Subject: Outpatient Orders

1.  Outpatient Orders

Posted 10-18-2017 17:44
What are the requirements for an outpatient order? I have tried explaining to the registration staff regarding medical necessity but they seem to not understand very well. Does any one know where I can find guidelines? Also what about verbal orders? The registration staff has been taking orders from nurses, can they do this?

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Cyli Torres
Medical Records Supervisor
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2.  RE: Outpatient Orders

Posted 10-18-2017 18:31

No they cannot unless it is a nurse practitioner with privileges.

 

Outpatient orders need dates, signatures and indications (diagnoses)






3.  RE: Outpatient Orders

Posted 10-18-2017 19:08
That's what I thought. Our problem is when we have orders and the diagnosis is not on there and the reg staff will call and get the diagnosis from a nurse or a front office staff member. I was enlisted to help do a training for them and am looking for any guidelines to help them understand.

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Cyli Torres
Medical Records Supervisor
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4.  RE: Outpatient Orders

Posted 10-19-2017 07:09
​Remember as well that a narrative is better than the actual diagnosis code itself.   There are regulatory and accreditation directives that require providers to supply documentation in order to support code assignment. Providers need to have the ability to specifically document the patient's diagnosis, condition and/or problem. Therefore, it is not appropriate for providers to list the code number or select a code number from a list of codes in place of a written diagnostic statement.   It is the provider's responsibility to provide clear and legible documentation of a diagnosis, which is then translated to a code for external reporting purposes.

Subject: Requirements for Ordering and Following Orders for Diagnostic Tests

 

  1. Policy: In order that payment can be made for diagnostic tests, there are certain ordering requirements which must be met. The requirements for both ordering and following orders for diagnostic tests are specified in this change request.

 

Order

An "order" is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y). An order may be delivered via the following forms of communication:

  • A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility;
  • A telephone call by the treating physician/practitioner or his/her office to the testing facility; and
  • An electronic mail by the treating physician/practitioner or his/her office to the testing facility.

If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary's medical records.



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Renee Friesen, CCS, CCS-P, AHIMA Approved ICD-10-CM/PCS Trainer
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5.  RE: Outpatient Orders

Posted 10-19-2017 07:54
​Good Morning,

We recently had a discussion at my facility regarding the need to have the diagnostic order filed in the current record for purposes of validating that the diagnoses (reason for visit) is valid and accessible to support the testing.  Apparently the order is filed in a secondary system and is not a part of the encounter created in our primary EHR.  Is anyone aware of any regulation or guidance on the need to have the order filed within the legal medical record?  All opinions welcome!
Thank you.

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Indra Osi
Enterprise Director Hospital Coding and Reimbursement
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6.  RE: Outpatient Orders

Posted 10-19-2017 08:10
​P.S.  Is it standard practice to use the clinical history/indications on the radiology report for reason for visit?  And does this negate the need to have the diagnostic order signed by the physician a part of the medical record?

Thanks!

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Indra Osi
Enterprise Director Hospital Coding and Reimbursement
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7.  RE: Outpatient Orders

Posted 10-19-2017 16:26

No it is not – and outpatient regulations are changing in 2018






8.  RE: Outpatient Orders

Posted 10-20-2017 16:27
​Adriana,

Do you have any documentation or references for the 2018 outpatient changes?

Thanks,

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Indra Osi
Enterprise Director Hospital Coding and Reimbursement
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9.  RE: Outpatient Orders

Posted 10-19-2017 10:18
​If an auditor looks at that chart they are going to ask where the order is or they may just say its missing the order.  I don't understand why the order is filed separately from the originating chart??   I've never seen that before.  Unless I just didn't understand your question.

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Kimberly Combs
Certified Coding Specialist
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10.  RE: Outpatient Orders

Posted 10-20-2017 16:26
​Kimberly,

Its a limitation in the new EHR we implemented.  The order is scanned into the old EHR.  I am told temporarily, but feel that in the interest of maintaining a unit record that the order should be scanned into the currently active EHR.  I also wanted to verify whether other facilities are using the radiology report which contains the clinical indication and history in lieu of the order as has been suggested that we do since it is a part of the EHR.

Thanks,

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Indra Osi
Enterprise Director Hospital Coding and Reimbursement
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11.  RE: Outpatient Orders

Posted 10-19-2017 09:55
​I think its asking too much for registration to check medical necessity.  We have CPSI system and when the patient goes back to the lab or x-ray  department they run the diagnosis through medical necessity in the system.  If it doesn't meet medical necessity the lab or x-ray will call the doctor for a new order with a new diagnosis that covers. If its a Medicare patient and the doctor doesn't have another diagnosis they let the patient know its not covered and then the patient has the choice of signing an ABN (making the patient responsible) or choosing not to have the test done.  It works great most of the time.

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Kimberly Combs
Certified Coding Specialist
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12.  RE: Outpatient Orders

Posted 10-19-2017 10:10
Edited by Kimberly Combs 10-19-2017 10:22
​To check medical necessity we refer to LCD's or NCD's.  Of course these are through CMS but some insurances follow medicare guidelines.  If the patient has BCBS you can usually look at medical policies on the BCBS website.  Hope this helps.  I'm an outpatient coder and I use these sites all the time.  I have LCD's and NCD's saved in my web browser for quick access.

All orders have to be issued and signed by a physician or PA or nurse practioner.  Sometimes we have to remind registration about verbal orders that they still need a doctors signature.  But otherwise things run pretty smoothly.




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Kimberly Combs
Certified Coding Specialist
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13.  RE: Outpatient Orders

Posted 10-19-2017 10:27

​If I read your question correctly, you have two issues; one issue is obtaining an order with a clinical reason for the ordered service and ensuring the service ordered meets medical necessity.

Do you have a compliance officer in your organization that can provide you with your state regs that define who can order a service, and who can sign orders?  Each state may have different regulations surrounding authentication of orders.  You may also reference the State Survey Manual Appendix A - Survey Protocol, Regulations and Interpretative Guidelines for Hospitals on the CMS website.  It provides specific requirements surrounding verbal orders, protocol, orders, etc.

Orders have to be provided by a physician, but a RN or medical assistant in a physician office works under the direct supervision of a physician and as such may be able to provide a "verbal order" which would be entered into the record as an order for the physician and subsequently routed to the physician for signature.  State regs may provide some guidance on this practice.

Medical necessity is another issue and another process.  Do you have a precert or preauthorization team in place?  Someone should be reviewing all clinical indications for outpatient services to ensure they meet medical necessity.  CMS as well as most payers have coverage policies on line to assist in making this determination.  When the service is not covered it may be necessary to contact the ordering physician and the patient with the cost of the procedure and obtain an Advance Beneficiary Notice from the patient.

Start with your state's licensing regulations for hospitals, review the CMS regulations surrounding outpatient services and standards as defined by your accrediting body if it is someone other than CMS.

I hope this makes sense!



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Mary Meysenburg, MPA, RHIA, CCs
Manager, Revenue Cycle Training
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14.  RE: Outpatient Orders

Posted 10-19-2017 10:36
Our process sounds fairly similar to what Kimberly's is.  We are a small critical access hospital and so we don't have an actual computer system that can check these so we check them manually.  We have trained all of our ancillary departments as to what policies they need to be aware of and to check them once they receive the order.  If it is not covered they are to call the physician for more info.  If still not covered then we issue an ABN.  Most of the time this works great.  There are times though that new employees are hired and are not trained on the policies yet.

If we receive an order that is a verbal or phone order then the receiving department will either write up a paper order or put this into the EHR order system.  It is then forwarded on to the physician for signature.  I believe the requirement for verbal or phone orders is that it is to be signed within 24 hours.  I'm not sure if this is just per our facility or if it is a general Medicare requirement.

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Mellissa Heimer, RHIT,CCS
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15.  RE: Outpatient Orders

Posted 10-19-2017 11:04
Thank you all for your help. I am still a little confused though when it comes to verbal orders.When the registration staff calls they 90% of the time will speak to the providers nurse to get a diagnosis. Is this acceptable? If so do we just need to make a note in that account? Does it need  to come from a provider or will a nurse be fine to provide the diagnosis?

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Cyli Torres
Medical Records Supervisor
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16.  RE: Outpatient Orders

Posted 10-19-2017 15:15

That works like a verbal order – you need a provider signature/authentication.  Do you have CPOE for outpatient?






17.  RE: Outpatient Orders

Posted 10-19-2017 16:16
​The nurse can give the new diagnosis over the phone, but you still need them to send you a new order with the new diagnosis and the physician signature.  We don't give them that choice, if the doctor provides a new diagnosis whether its the nurse relaying the message or not, we have them send the new order over immediately because they have been known to get busy and forget to send the order.  So I would make the patient wait until you receive the new order.  I know that can be inconvenient for the patient at times but you have to meet medical necessity if you want to get paid. I think it looks fishy or throws up red flags to wait until you get denied, then ask for a new diagnosis, not to mention that holds up payment as well.

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Kimberly Combs
Certified Coding Specialist
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