Wiki Billing/coding/modifiers

[liswoo]

Hospital billing/coding: shouldn't there be a physician's order in the patient's record for the service we are coding and billing for? For example, patient has shoulder surgery with general anesthesia and a CRNA administers an interscalene block for post op pain control.....shouldn't we have an actual physician's order in the patient's record in order to bill for that block?

 

[thomas7331]

Physicians and NPPs are not required to write an order for services that they personally perform. An order is required for diagnostic tests and any other supplies or services furnished by non-physician hospital auxiliary personnel in order to meet the CMS coverage requirement that those services were provided incident to a physician's service. In your example, the MD performing surgery and the CRNA are eligible providers and their own documentation and attestation in the record that they provided these services would be sufficient to meet this requirement - there's no need for a separate order.

 

[liswoo]

Physicians and NPPs are not required to write an order for services that they personally perform. An order is required for diagnostic tests and any other supplies or services furnished by non-physician hospital auxiliary personnel in order to meet the CMS coverage requirement that those services were provided incident to a physician's service. In your example, the MD performing surgery and the CRNA are eligible providers and their own documentation and attestation in the record that they provided these services would be sufficient to meet this requirement - there's no need for a separate order.

Thank you so much Thomas. I greatly appreciate the response! Have a good weekend.