485 whoo's

from: cahaba medicare

80.40 [color=#231f20]verbal/oral orders

medicare benefit policy manual [color=#231f20](cms pub. 100-2, ch.7 30.2.5)

a physician's verbal order to provide services may be accepted and put in writing by personnel authorized to do so by state and federal laws and regulations, as well as by the hha's internal policies. the orders must be

signed and dated by the physician, with the date of receipt by the registered nurse or qualified therapist (i.e., physical therapist, speech-language pathologist, occupational therapist, or medical social worker) whom the agency has designated responsible for furnishing or supervising the ordered services.

on occasion, a verbal order is received but not documented. in the absence of documentation of verbal orders, a notarized statement from the physician that he/she gave verbal orders before the services were provided is acceptable. the orders may be signed after the services have been provided as long as the hha personnel who received the verbal orders notifies the nurse or therapist before the service is provided. this allows the services, based on the verbal order, to be provided without delay pending the signature. please note that the notarized statement from the physician [color=#231f20]must [color=#231f20]also be signed and dated before the services are billed to medicare.

it is appropriate to use verbal orders for:

- [color=#231f20]services provided from the beginning of the certification period and before the physician signs the plan

of care

- [color=#231f20]services provided in the subsequent certification period (recertification) before the physician signs the

recertification plan of care

- [color=#231f20]any change in the plan of care (e.g., change in the frequency of services or the addition of new

services) during a certification period

80.45 [color=#231f20]services provided before physician signs the certification plan of care

medicare benefit policy manual [color=#231f20](cms pub. 100-2, ch.7 30.2)

a physician's verbal order for services must be obtained before services are provided. this applies to services provided from the start-of care-date for the certification period until the physician signs the certification plan of

care. the verbal order must be documented in the medical record and the services included in a signed plan of care. the verbal order must include, at a minimum, the type of services to be provided, the discipline providing

the services, and the frequency at which the services will be provided.

80.35 - 80.45