Wiki In Office procedures

[sandyblanco2020@gmail.com]

Hello,

I recently started billing for a Neurology Group and I am having trouble with providers and other staff understand the importance of entering orders for procedures such as Botox, ONB Injections, EEG, TCD, EMG, VEEG, ect. They state that they have been doing these procedures for over 8 years and they have never entered an order in the patients chart because the providers document it recommendation in the treatment plan part of the patient encounter.

Have I been doing this wrong the whole time? are orders not required for procedures? and are orders date specific? Im so confused, can someone please help me.

 

[Jamitch1984]

It is always best practice to have an order. But I see if they are stating the visit note contains it could suffice depending on the procedure. Would have to check documentation requirements for each procedure.

 

[Pam Warren]

Orders are a hospital requirement, not necessarily a practice requirement. If your office is a provider-based practice (an outpatient hospital department) then they are required to write an order. In a practice setting (POS 11), an order for an in-office procedure is not a requirement, particularly if it's documented in the treatment plan.