Wiki Do they Count- orders only referenced

[Kristen Bensel]

If a provider determines that the patient needs to be assessed by a specialist, orders medications, imaging or lab work... but the orders for these is not actually captured in the note as legit orders- does this still count?

I know the orders can technically be seen in the medical record, but because they are not in the note itself, can they be used to level the visit? Or is the providers statement that they are going to do these things enough?

Personally I feel that if it isn't captured in the note documentation, then it doesn't count. The payer or auditor can't see our EMR to know if those orders were really placed or not. I have had instances where the provider says they are going to do these things and they didn't actually do it, or they had done it during previous visits... so if I used their "word" as support of the level we would have been giving money back to the payer.

Our templates are set to automatically pull orders placed that day into the note, but only orders that are placed prior to the note being started. The providers are able to manually drop the orders into the note, it is just an additional step they have to do... So before I pick a fight with a few providers, I am curious what others opinions are about this.

 

[Cls1530]

If a provider determines that the patient needs to be assessed by a specialist, orders medications, imaging or lab work... but the orders for these is not actually captured in the note as legit orders- does this still count?

I know the orders can technically be seen in the medical record, but because they are not in the note itself, can they be used to level the visit? Or is the providers statement that they are going to do these things enough?

Personally I feel that if it isn't captured in the note documentation, then it doesn't count. The payer or auditor can't see our EMR to know if those orders were really placed or not. I have had instances where the provider says they are going to do these things and they didn't actually do it, or they had done it during previous visits... so if I used their "word" as support of the level we would have been giving money back to the payer.

Our templates are set to automatically pull orders placed that day into the note, but only orders that are placed prior to the note being started. The providers are able to manually drop the orders into the note, it is just an additional step they have to do... So before I pick a fight with a few providers, I am curious what others opinions are about this.

I would want anything being used for medical decision making to be in the note unless it is something after hours. That being said, if insurance were to request documentation you could send all relevant records for that date of service.

 

[csperoni]

I agree with @Cls1530 that it would certainly be a "best practice" for the note itself to contain all the MDM components for that day. However, if it is documented elsewhere but still part of the records, I would count it. If there were a particular provider or practice that were consistent outliers about this, I would provide education.