American College of Physicians: Internal Medicine — Doctors for Adults ®


CMS changes hospitals rules for completing history and physical documentation

Also, overcome obstacles to getting abdominal aortic aneurysms covered for patients

From the April ACP Observer, copyright 2007 by the American College of Physicians.

By Brian Whitman

Practice RxQ: The hospital has told me that I have to document my inpatient work in a different way? Why are they doing this?

A: Hospitals are subject to regulations from a wide variety of entities, from state agencies to accreditation bodies. Recently, the CMS implemented a rule change to the Conditions of Participation that hospitals must follow in order to bill Medicare for services.

These new rules affect physicians by changing the time restrictions for the completion of a history and physical and changing the documentation requirements for orders. Hospitals must follow federal and state regulations and accreditation standards, but may also enact rules that are more restrictive than these requirements. In order to be members of a hospital medical staff, physicians must follow the rules of that hospital. You should expect to see more from your hospital if changes will occur based on this new rule.

Q: When am I required to perform a history and physical on a hospitalized patient?

A: Before this new rule took effect on Jan. 26, a patient had to have a history and physical performed no more than seven days prior to admission or no more than 24 hours after admission. Due to complaints from some physicians that this was an undue burden that did not match current practice patterns, the new rule expands the time before admission at which the admission history and physical may take place. This exam may now take place as early as 30 days prior to admission, according to the new rule, but still may not be performed more than 24 hours after admission.

There are times in which surgeons request primary care physicians to complete history and physical exams for their patients prior to admission for a procedure of some kind. A physician may perform this exam, even if he or she is not a member of the medical staff at which the patient is scheduled to receive the procedure.

Q: Do verbal orders have to be signed?

A: The CMS rule also addressed the issue of documentation of orders in the hospital setting. There were two changes of note that occurred with the implementation of this rule.

The first change addressed the issue of who may sign a verbal order. In the past, the physician who issued the order was required to authenticate or sign the order. With this new rule, any physician who is responsible for the care of the patient and is eligible to make orders in the hospital may authenticate a verbal order made by another physician. A physician is not required to authenticate another physician's order because of this rule.

The second change addresses how long after issuance a verbal order would have to be signed. The new rule requires that all orders must be authenticated within 48 hours. There are some states that have laws that require orders to be authenticated more quickly than this.

The conditions of participation for hospitals repeatedly stress that verbal orders should be a rare occurrence in the hospital setting because of the potential patient safety issues caused by a misheard verbal order. This rule intends to minimize the impact of these problems.

Q: How will they know if an order was signed within 48 hours?

A: The rule also requires that all medical record entries in the hospital chart have a time included. Most people who enter information in the chart are used to including the date, but the time must now be included as well. This requirement is not only for authentication of verbal orders but for all elements of the inpatient medical record.

AAA service

Q: I have patients who meet the risk factors for ultrasound screening for abdominal aortic aneurysm, but since Medicare does not cover this service, these patients cannot afford to get the procedure. What should I do?

A: Medicare has historically not paid for preventive services, only adding a few at a time through legislative action. (See "Your Practice").Coverage for this service began on Jan. 1 but Congress specified some requirements that may make it difficult to refer patients and for the physician reading the test to get paid. As a new benefit mandated by Congress, it will not be subject to budget neutrality requirements that would reduce the value of other services.

The biggest obstacle to the coverage is that, in order to be paid, the patient must be referred for the screening during the Initial Preventive Physical Examination, also known as the "Welcome to Medicare" exam. This is the preventive visit that was introduced in 2005, covering a screening exam for patients in their first six months as a Medicare Part B beneficiary. The number of eligible patients who receive the "Welcome to Medicare" exam is quite low, however. This means that patients who have been on Medicare for more than six months and who have not had the screening exam cannot receive the benefit.

Q: Who is eligible to be referred for the benefit as paid by Medicare?

A: Beneficiaries who meet the conditions set forth by the U.S. Preventive Services Task Force (USPSTF) are eligible to be referred for the screening and have it covered by Medicare. The current guidelines allow payment for males between the ages of 65 and 75 who have smoked at least 100 cigarettes in their lifetime.

The regulation allows for additional Medicare beneficiaries to be eligible for this exam if USPSTF recommendations change in the future.

Stay up-to-date with CMS

Q: Is there a way to hear directly from CMS about issues that affect physician payment from Medicare?

A: CMS puts out a lot of information that is relevant to physicians on its Web site and disseminates information through various e-mail services. CMS maintains a "Physician Center" on its Web site where it stores all material that may be relevant to physicians. There is a great deal of material produced, so it can take some time to sort through everything in order to find material that may be relevant to you.

In addition, CMS offers conference calls that it refers to as "Open Door Forums" on a regular basis, usually monthly. These phone calls allow lead staff on various CMS initiatives to share information about new regulations and ongoing projects. The Open Door Forums are usually announced about two weeks before they take place. More information about Physician Open Door Forums can be found online.

Anyone who wishes can participate in these phone calls.

Brian Whitman is senior analyst for Regulatory and Insurer Affairs in ACP's Washington office.


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