Wiki Are Orders Required for Injections Administered Within the Office?

[KStaten]

Hello, Everyone. I have a couple of questions that I am hoping you can confirm, as I am being given mixed answers.

1) Are orders required for injections administered in the office (such as Depo-Medrol) or is standard documentation of the injections in the notes sufficient?

2) Who may enter the orders for injections in the EMR system and is there a time limit? (For instance, could these be entered and/or corrected by a transcriptionist afterwards if the doctor documents the injection in the note but either fails to enter the order or accidentally enters an order with erroneous information?)

As always, thank you in advance!
Kim

 

[thomas7331]

To question 1): With few minor exceptions (such as for some vaccinations which may be administered based on a 'standing order') physician (or NPP) orders are required for all treatments administered to patient by ancillary staff. I don't believe a physician needs to write an order for services they personally perform.

To question 2): Although the office staff may enter orders into the EMR, or document a verbal order given by the provider, the physician must personally sign the order. If the order is not signed, some payers and auditors would likely still consider it a valid order if the physician has clearly documented it in their care plan for the patient. Retroactive or backdated orders are generally not allowed by payers - an order written after the service was already performed would not be considered valid.

 

[KStaten]

To question 1): With few minor exceptions (such as for some vaccinations which may be administered based on a 'standing order') physician (or NPP) orders are required for all treatments administered to patient by ancillary staff. I don't believe a physician needs to write an order for services they personally perform.

To question 2): Although the office staff may enter orders into the EMR, or document a verbal order given by the provider, the physician must personally sign the order. If the order is not signed, some payers and auditors would likely still consider it a valid order if the physician has clearly documented it in their care plan for the patient. Retroactive or backdated orders are generally not allowed by payers - an order written after the service was already performed would not be considered valid.

Okay, I reread this. So, if a provider is personally administering the injection, then an order is not needed? This would also mean there would be no need for a retroactive order (which as you stated would more than likely not be valid anyways) as long as the provider has documented the injection in the note. Thanks for the input!

 

[thomas7331]

Okay, I reread this. So, if a provider is personally administering the injection, then an order is not needed? This would also mean there would be no need for a retroactive order (which as you stated would more than likely not be valid anyways) as long as the provider has documented the injection in the note. Thanks for the input!

That is my understanding - if the provider is doing it themselves, it's self-evident that they are ordering it. For example, it would not make sense to require a surgeon to go back and write orders for steps that they take during the course of a surgery. But they do need to document the procedures themselves and the reasons they're doing them to support its medical necessity.

 

[clairissa_kelley]

@thomas7331 I am wondering if you have documentation you can share to support your rationale. Thanks!

 

[thomas7331]

@thomas7331 I am wondering if you have documentation you can share to support your rationale. Thanks!

I can't point you to a specific regulation, and the answer I always give to questions like this is that laws and regulations tell you what you are required to do, they don't tell you what you don't have to do. So you will find regulations requiring orders for entities that carry out those orders, but you won't find documentation stating that physician do or don't have to write orders for themselves because I don't think there are any.

The purpose of physician orders is to show that a particular service was a part of a physician's or NPP's plan of care for the treatment of an illness or injury - this is a coverage requirement under Medicare law. So this applies to hospitals, labs, diagnostic imaging facilities, infusion centers, home care agencies, etc. as well as to non-physician staff members in the physician office who may be acting 'incident to' the physician. All services rendered by these provider types must have valid orders in place for every service in order to meet that requirement that the service performed for the patient was a part of the plan of care. A physician doesn't need to write orders to themselves - orders are just for those services that are referred out to non-physicians to be performed. CMS and regulatory agencies do not audit services performed by physician for orders. It would be an enormous administrative burden if a physician had to write a separate order for everything that they themselves performed for a patient and would be absurd to require them to.