Landmark Change to Verbal Orders in the Conditions of Participation

(PYA Alert dated February 21, 2007)

How long has the battle been waged with physicians over countersignature of their own verbal orders, in accordance with longstanding CMS’s Conditions on Participation (CoP)? If you haven’t yet caught up with the final CoP regulation as published in the November 27th Federal Register, a landmark change has taken place.

CMS continues to caution that providers should not make routine use of verbal orders, due to the increased potential for error. However, an exception in the final regulation now outlines that another physician responsible for a patient’s care, such as a partner in their practice, can authenticate the original physician’s order within the allotted 48-hour time frame, unless state law specifies a different provision (be sure to familiarize yourself with your state’s provisions). Further, CMS indicates that “physician extenders”, such as physician assistants and nurse practitioners, may authenticate physician orders, provided that the physician extender is licensed to perform the services reflected in the verbal order.

In anticipation of ultimate widespread use of electronic medical records (EMR), which should largely resolve the countersignature dilemma, CMS has limited this exception to a period of five years. In the interim, HIM Departments will need to educate their organizations and medical staff on regulation content, align department processes accordingly such as chart analysis, and, provide HIM staff training. Hospitals will want to ensure that policies and/or the rules and regulations section of medical staff bylaws reflect this change as well.

Has this information been helpful? It’s hard to keep up with so many changes in the health care industry. PYA's credentialed health information professionals are prepared to assist with your facility’s HIM compliance needs including operations, coding and DRG validation, documentation improvement, business strategy, education, and many others.

Please contact Carol Eyer at (800) 270-9629 for more information.

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