OASIS Alert

Question: We have operated under the guidelines that a physician must sign all home health orders as well as the plan of treatment. The Medicare Policy Manual seems clear about the plan of treatment and face-to-face encounters, but doesn't address routine orders specifically. We have recently been working with a new Advanced Registered Nurse Practitioner (ARNP) who insists she has her own patients; can sign orders, prescriptions, and home health orders. She continues to return our faxed orders with only her signature. Can you help us to find something in writing to help with this situation?

Illinois Subscriber

Answer: The U.S. Code of Federal Regulations Title 42, Part 409, Section 409.43 includes the following language concerning physician signatures "Request for Anticipated Payment signature requirements. If the physician signed plan of care is not available at the time the HHA requests an anticipated payment of the initial percentage prospective payment in accordance with 484.205, the request for the anticipated payment must be based on a physician's verbal order that (A) Is recorded in the plan of care; (B) Includes a description of the patient's condition and the services to be provided by the home health agency; (C) Includes an attestation (relating to the physician's orders and the date received) signed and dated by the registered nurse or qualified therapist (as defined in 42 CFR 484.4) responsible for furnishing or supervising the ordered service in the plan of care; and (D) Is copied into the plan of care and the plan of care is immediately submitted to the physician; or a referral prescribing detailed orders for the services to be rendered that is signed and dated by a physician." There is no exception for care provided by non-physician practitioners.

In addition, the Benefit Policy Manual, Section 30.2.5 -- Use of Oral (Verbal) Orders says nothing about non-physician signatures, says Karen Vance, supervising consultant with BKD in Colorado Springs, Colo. "As we know from the Face-to-Face language inserted into the manual, when a non-physician signature is allowed, they include that in the language," she tells Eli.

"Special rules for payment of care plan oversight provided by nonphysician practitioners (NPP) for beneficiaries who receive HHA services covered by Medicare. (1) An NPP can furnish physician care plan oversight (but may not certify a patient as needing home health services) only if the physician who signs the plan of care provides regular ongoing care under the same plan of care as does the NPP billing for care plan oversight and either the physician and NPP are part of the same group practice; or if the NPP is a nurse practitioner or clinical nurse specialist, the physician signing the plan of care also has a collaborative agreement with the NPP; or if the NPP is a physician assistant, the physician signing the plan of care is also the physician who provides general supervision of physician assistant services for the practice." (Emphasis added.)