Start of care orders

[Sana2007]

Wondering how other agencies handle the requirement of getting authorization for orders prior to implementing the order specifically at start of care? From talking to a lot of nurses and therapist I have come to found out that they do not call the physician after assessing the patient unless there is something really unusual. And we know that referral orders almost never address any orders like frequency/duration....But that means that they start revisiting patients long before 485s/POCs come back signed and I have read several places that Medicare sometimes deny these visits; the visits after the eval until the date MD signs the POC, because there is no evidence of verbal authorization. So I am wondering if clinicians just sign there orders as verbal so that it looks like the MD was contacted or do they ask the MD to back date it because I can't think of any other way of handling this except to actually just pick up the phone and call. Please help. Thanks

[TejasRN]

You must call the MD after the initial assessment to get verbal orders. Most often it's given by the office staff. So I put V.O. Dr.Smith/Nancy Nurse RN/my name, date and time. If you are having a hard time getting orders that's what your Clinical Supervisor is there for. State surveyors want to see evidence of this when they visit. You also need a verbal order for physical therapy plans of care. You just can't order it for the patient. Even if you get an order for a PT eval on the initial referral, the order is for an eval only.

Cover you butt our surveyors here in Texas are brutal, don't ever back date anything it's considered fraud.

[berube]

our clinical supervisors have told us up front that it is OUR job to get that order,,,i agree it is, but when we are having a difficult time getting it, or a day with 9 patients and virtually no time for a BR break, or they call and add something to our day, you would think they could help us out!!!!!!!!! i have worked "both" sides in the field, in the office and back in the field, i would do anything to help my nurses out.

[Sana2007]

You must call the MD after the initial assessment to get verbal orders. Most often it's given by the office staff. So I put V.O. Dr.Smith/Nancy Nurse RN/my name, date and time. If you are having a hard time getting orders that's what your Clinical Supervisor is there for. State surveyors want to see evidence of this when they visit. You also need a verbal order for physical therapy plans of care. You just can't order it for the patient. Even if you get an order for a PT eval on the initial referral, the order is for an eval only.

Cover you butt our surveyors here in Texas are brutal, don't ever back date anything it's considered fraud.

I haven't found any therapist yet who calls to get verbal orders. We have contract with big therapy companies and then some smaller companies but they all think we are asking them some thing completely out of their realm when we say if they call the docs themselves. They are much highly paid than us nurses but sadly do half as much we do. I am cornced about there revisits too without any evidence of verbal authorization. "Eval and Treat order" is only good for that one eval visit not the revisits. And sometimes by the time we get our hands on their evals, they are already into there third week seeing the patient. Technically intermediary can deny all these visits!

[HmarieD]

ok, sooooo does it mean that we can still just call , leave a message like we always have, but if we are answering yes to any of the items in M2250 then we "truly" need to have that 2 way discussion???????

Yes, with documented evidence of that communication.

[paradiseboundRN]

I can't even get the Dr's to call me back when the pt is having a problem! They are certainly not going to return a call to discuss frequency of visits, etc. I leave a message with his receptionist unless I need clarification or there is a problem with the patient. I have never heard of Medicare denying SOC visits for those reasons.

[tewdles, RN]

I can't even get the Dr's to call me back when the pt is having a problem! They are certainly not going to return a call to discuss frequency of visits, etc. I leave a message with his receptionist unless I need clarification or there is a problem with the patient. I have never heard of Medicare denying SOC visits for those reasons.

This is clearly one of the advantages of working in hospice as opposed to home care...if I need an MD consultation and the primary does not respond to my attempts to contact her, I can call the medical director. When I worked in home care I was frequently frustrated in my attempts to speak with doctors and felt that care was hampered because of the difficulty.

[berube]

we don't even have a medical director!!!!!

[berube]

we don't even have a medical director!!!!!

i should clarify that, we are home health and this is the first one i have worked at that does not have a medical director. other agencies, we could use the medical director to help us out when we could not get a response from the PCP.

[TejasRN]

I can't even get the Dr's to call me back when the pt is having a problem! They are certainly not going to return a call to discuss frequency of visits, etc. I leave a message with his receptionist unless I need clarification or there is a problem with the patient. I have never heard of Medicare denying SOC visits for those reasons.

Reality vs Medicare Rules and Regs = Home Health can be a big pain in the butt!

Meddicare does not deny visits, Medicare is your payer, you get denied payment if your episode is not billable for whatever reason, IF the Medicare contracted auditor audits the episode. In Texas we are also licensed by the state. The state survey is where you have problems with issues like no verbal start of care orders, lack of communication with the MD, lack of supervision of HHA, LVN's, no skilled visit and whatever else they can dig up. It is difficult to get initial orders but it is a requirement. Some say the signed 485 is the order but it's really not. You may get a surveyor who doesn't make a federal case of it, which is nice!

[Abbies]

Our office staff sends out continuation orders the same day they received the signed referral for eval. and treat. We usually have revisit orders back within 1 to 2 days. If we need to revisit on day 2 we must have a VO from the doctor. We cannot touch a client with saline or even a band aid without a verbal order. If I can't talk to an RN or don't get a response back after calling, my office staff will fax (or re-fax). I let the person on the other end of the phone know I can't take care of the patient until we get an order and if the doctor is occupied, they will usually stick a fax under his nose for sig and fax it back to us. Otherwise......the patient has to wait. Most docs & their staff respond quickly, it's the surgeons that I have the most trouble with because they are usually only in 1-2 days a week or must be paged during surgery for urgent matters.)

[jaej]

The answers are in the medicare guidelines/cop. Pt. being d/c, intake will obtain order from attending md (who will usually never see pt again. Intake documents receipt of vo for eval. MD will not order freq at this point b/c eval in home has not been done yet, therefore needs have not yet been determined. nurse will go to home, eval, then is required by medicare to document communication with the MD who will oversee POC and sign 485. This is usualy the pcp. The reason for this communication is to verify that vo have been received by the MD BASED on the eval done in the home. This is the MD who will be signing 485. You now have vo to carry out frequency based on the eval. Our agency uses an OASIS form w/ a box to check verifying that you contacted the md and they approved the orders. You can only see the patient again if that box is checked as per medicare guidelines as that indicates that you received vo from the md, or an agent of the md based on the eval. Of course they usually dont care about your frequency, but regulations state that that communication must take place as receipt of vo. The md who ordered a soc cannot sign the 485 unless they actually oversee the plan of care! They can order that you may also take orders from card., urology, etc., but the MD approving the freq, and signing the 485 must have that pt UNDER THEIR CARE for the cert period. If not ,it is fraud by the MD signing the POC (they usually bill medicare for "oversight of poc"), and if the nurse checks "yes" and actually has not contacted the MD, he/she is committing fraud, AND the agency may not be able to get paid for the episode if the MD refuses to sign the 485 usually because it is the hospitalist, rehab doc who will not be following the pt post discharge and therefore not overseeing the plan of care. A word of advice-many agencies want that box checked so that they can go ahead and start the episode (PPS), but if you are the admitting nurse, and have not been able to make that communication, you cannot check that box. You, will be charged with fraud when the agency puts the heat on the md to sign it so that they can get paid, and they say they never approved the freq, because they never agreed to follow the patient because they are the rehab dr, hospitalist, etc....Hope this helps!

[MindyTX]

Your explanation is exactly correct. the Verbal SOC date has nothing to do with coordinating care with the physician at the SOC visit. It only gives us the ability to evaluate the patient. Even if we had very specific orders and frequency when the referral came in, it is required that nurses call the MD office and discuss findings, plan or deviation from plan, concerns etc. Home health is low priority in most MD offices and we commonly get voice mail. If I get voice mail I just indicate I evaluated, any imediate concerns, and freq. and ask that someone call me by the end of the day if they disagree with plan. If you do not get a call by the end of the day yuo have orders and also gave the MD or nurse the option to not have to make another call. I also fax a narrative to MD on the day of eval or next.

Document your voice mail message and that you faxed a narrative and you have done everything the conditions of participation request.