Medicare Compliance & Reimbursement

Warning: These changes could affect your facility’s current protocols.

Facilities and health care providers must comply with the new requirements of minimum health and safety standards, known as conditions of participation (“CoPs”), laid down by the Centers for Medicare & Medicaid Services (CMS) in order to qualify for Medicare certification and reimbursements. Read on to find out how these CoPs, the related terminology and other details could affect you and why you need to have a clear understanding of them.

CoPs Implementation: What Needs to be Done

Almost all hospitals and nursing facilities develop and follow protocols of some kind, but not all are properly standardized, referenced and documented well enough to face an audit.

You need an overall general process for developing, maintaining, and applying these standing orders, orders sets, protocols, pre-printed forms, advises Duane C. Abbey, Ph.D., of Abbey and Abbey Consultants Inc., in Ames, IA. As an overview, you’ll need to:

• Have a general policy and procedure for the establishment, maintenance, and proper application;
• Make sure the policy and procedures are readily available during an audit;
• Ensure orders are medically sound and applied appropriately;
• Make sure that your protocol is updated and not obsolete.

Vital: Significant interaction with the medical staff organization holds the key to a successful implementation of the process, says Abbey.

Resource: The Federal Register addressed topics that hospitals need to be aware of and conform to as far back as 2012. The most recent Federal Register (released on May 12, 2014 with an effective date of July 11, 2014) outlines issues generally pertaining to the CoPs such as radiology services in ambulatory surgical centers (ASCs), critical access hospitals (CAHs), physician responsibilities, and more.

Brush Up on Definitions and Terminology

The State Operations Manual (SOM) states that, “There is no standard definition of a standing order in the hospital community at large (77 FR 29055, May 16, 2012), but the terms ‘preprinted standing orders,’ ‘electronic standing orders,’ ‘order sets,’ and ‘protocols for patient orders’ are various ways in which the term standing orders has been applied. For purposes of brevity in our guidance, we generally use the term ‘standing orders’ to refer interchangeably to preprinted and electronic standing orders, order sets and protocols. However, we note that the lack of a standard definition for these terms and their interchangeable and indistinct use by hospitals and health care professionals may result in confusion regarding what is or is not subject to the requirements of §482.24(c) (3) particularly with respect to ‘order sets’ (TAG 0457).”

In the face of this ambiguity, having a clear understanding of CoP terminology will help you accurately develop your policies and protocols, says Abbey.

Standing orders: Standing orders are the orders that may be initiated by nursing or other qualified staff if the patient meets certain criteria (such as the ED providing oxygen, hydration and/or therapy). The hospital should develop the standing orders keeping in mind the following.

1) Must be based on nationally recognized and evidence-based guidelines and recommendations.
2) Must contribute to patient safety and quality care by providing evidence based medicine and standardization.
3) The rationale for the order should be explicitly stated within itself as it is a Medicare audit requisite. Example: In the emergency department a standard protocol might be to provide oxygen and start an IV. You should include a rationale to justify the protocol.
4) The standing order should have clearer instructions in terms of when nursing staff should do a specific action. What are the criteria that they’re going to use to make a specific decision? Sometimes, this will occur before the patient is seen by a physician.

Examples of areas where standing orders apply include the triage nurse being given the power of criteria based decision making to order laboratory tests, radiology tests for faster provision of health services, Abbey shares.

Verbal orders: Verbal orders and authentication of orders are a very critical issue. Though executed, they still need to be authenticated and documented. “Many times auditors find that hospitals simply do things and the provider misses out on the authentication and documentation part. Although the requirement for authentication of verbal orders within 48 hours has been eliminated, state laws establish authentication timeframes. Nonetheless, it is desirable to get verbal orders authenticated within 48 hours. You may need to check with your state law for the authentication timeframes,” says Abbey.

Order sets: These are a list of individually selected services from which the ordering physician/practitioner can choose. Example: Post-surgical services for post-surgical care, where the provider can make an appropriate choice of drugs, analgesics, and sleeping aid to be used from the ones available.

Pre printed order sets: These are simply order sets that are developed, approved by the medical staff and are standardized in printed form. They are intended to help the physician and may be physician specific.

Protocols: These are services that are provided when the patient meets certain clinical criteria. However an order must be given to start the protocol. Example: Most hospitals will have a chest pain protocol or an abdominal pain protocol. The physician has to give an order to start it, and he will himself follow this protocol as well. The protocol involves at least placing the patient in observation, ordering requisite lab or X-ray tests, giving medications, etc.

Ace advantage: The use of standing orders contributes to patient safety and quality care by providing evidence based medicine and standardization. Using these types of orders will facilitate:

• A faster implementation of care for patients.
• Less procedural burden.
• Physicians spending more time on directly providing care to patients.
• Other providers taking on additional tasks and simplifying administrative processes.