The Ins And Outs of The CMS Verbal Order
CMS verbal orders are dictated verbal directions or instructions that are provided by an authorized healthcare provider for the purpose of shaping the course of a patient’s care in a healthcare facility. These orders are received either directly by a nurse, or indirectly by an auxiliary staff member who acts as a messenger to deliver the verbal orders. The nurse is responsible for transcribing the order to the patient’s medical records and communicating the directive to other staff members involved in the patient’s care. In cases where patients are receiving home health care services , nurse must communicate the verbal order it to the patient’s health agency. Verbal orders are an essential aspect of care in both long-term care facilities and home health care settings. They are applicable in numerous medical scenarios. For instance, a patient may be prescribed bed rest until a follow-up evaluation can be made on Wednesday. In the case of a diabetes patient, a verbal order could be given to administer an insulin injection for a sudden spike in blood sugar. A verbal directive for a home health aide may be given a nurse to clean a patient’s tracheostomy tube in certain set intervals. Because verbal orders are common in healthcare facilities and hospitals, the Centers for Medicare and Medicaid Services (CMS) has stepped forward with specific requirements to guide the use of these verbal directives for patient care.
Rule and Regulations Pertaining to Verbal Orders
Under federal Medicare statutes, covered services require a "physician’s order" that specifies the services a patient needs before care is furnished. 42 USCS § 1395x. A "physician’s order" may be written or verbal. 42 USCS § 1395x. Medicare provider/supplier regulations include specific requirements for physician orders for the various types of services a provider may furnish.
CMS’ rules on verbal orders are set forth in the Medicare Benefit Policy Manual at Ch. 7, § 150 (Guidelines for Accepting Orders) and § 155 (Orders for Hospice Services). Verbal orders for clinical diagnostic laboratory tests also are governed by the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 USC 263a(a)(1), which requires labs to maintain written orders for services. 42 CFR §§ 493.1240(a), 493.1281(e), 410.32(d)(3). CLIA also provides for verbal orders for outpatient drugs and blood products; the health care professional who gives the verbal order must sign the hard-copy order within 48 hours, and the hard copy order must include the date of the verbal order and indicate that it was given verbally. 42 CFR § 482.23(c)(2). CMS regularly revises its ultimately applicable laws and regulations, and the manual guidance incorporated in them, as CMS interprets existing laws and regulations and as healthcare and new technologies evolve. A provider/supplier remains always responsible for knowing CMS policies and complying with them. Providers are encouraged to regularly check for changes in the Medicare program manuals and updates.
Verbal Order Best Practices
CMS has specific guidance on its expectations for verbal orders and what providers must do to ensure compliance. Failure to follow CMS’s requirements can have a negative impact on your facility, such as an extended stay with the Recovery Audit Contractor (RAC) or an increased sample size for your next RAC probe sample. They may also turn around and deny claims for the "non-compliant" sample claims.
You should be mindful of this when implementing verbal orders in your facility. Best practices for implementing and utilizing verbal orders will not only help avoid adverse determinations by regulatory contractors, but can also make verbal order utilization more effective for your physicians.
Here are some best practices for implementing and utilizing verbal orders in your facility:
- Implement consistent policies and procedures related to verbal order use, which reflect CMS guidance.
- Educate staff and physicians on the verbal order policies and procedures.
- Ensure that the verbal order policies and procedures are available and understood by all staff and physicians utilizing verbal orders.
- Post sample order forms in physician’s offices and within the facility and work to obtain a copy of the physician’s printed order sheet, if available.
- If your facility does not have a prescription pad for your physicians to use to write verbal orders, establish an internal system for obtaining verbal orders from physicians.
- Ensure that you have a process for checking and validating verbal orders.
- Familiarize yourselves and educate your staff on physician names, titles and initials to minimize any conflicting or inconsistent interpretations of the orders.
- Immediately after a verbal order is received, staff should write the order as soon as possible in the medical record or chart. If using a verbal order pad, make sure the printed orders are legible and will appear clear and easy to read in the medical record.
- For nurses and other practitioners: draw a line through the section in the chart or medical record where the earlier, incorrect order was located and make sure that the correct order is documented in the chart or medical record below the incorrect order and noted as a correction. The correction should be initialed by both the nurse or practitioner and the physician, and should also include the date and time. The correction should contain only sufficient information to correct the erroneous entry. Any changes made should not contradict or change the overall medical records.
- Establish a system in the facility for reviewing all verbal orders and ensuring that they are properly executed and validated by the physician to become valid orders.
Documentation and Verbal Orders
For all verbal orders, CMS documentation and record-keeping requirements must be maintained, the timeframes of which must coincide with the timeframes for the Start and Stop Times used for some services. For example, for a home health certification, the start time of care must not be prior to the first date of the physician-ordered home health visit, and the stop time of care must not be after the nursing visit that ends the certification period (i.e., the last face-to-face encounter by any nurse employed by the agency).
Some providers may have already been performing many elements required for an effective and appropriate verbal order process. This new guidance provides additional clarity on the documentation that supports compliance. Medicare contractors and surveyors will use Reasonable and Necessary Expectations for Factors When Investigating and Evaluating Compliance and Conformance for Verbal Order Documentation.
Documentation and record-keeping requirements for verbal orders include:
Date and Time of Order
• Indicate on the order itself or in the clinical record when the order was written
• In the absence of both of these, the date, location, and time when the order was communicated to the responsible clinician must be documented
H&P Requirements
• The timing of the documentation of the order must include additional documentation consistent with the H&P requirements for the service or supply when the service or supply is ordered, including the date and the time (in military time) the order was written
• For services or supplies ordered as part of the H&P, reference must be made to the H&P in the documentation of the order
• For services or supplies ordered after the H&P has been completed but before the order is documented, the date the H&P is completed must be documented in the clinical record
• If the order is for a home health certification, documentation of the order must also include start and stop times for the provision of services . The start time of care must not precede the first date of the physician-ordered HH visit, and the stop time of care must not exceed the visit that ends the HH certification period (which is the skilled nursing visit that occurred before the start of the subsequent certification period)
Physician Signature and Identification
• A verbal order is inadvertently not signed if the physician or NPP fails to sign the order when typically done – this does not mean the order itself must be dated and timed if not customary. It would, however, mean that in such cases, if the physician or NPP does/did not sign the order, then he/she must sign and date it at a later date to be compliant
• Documentation must include the physician’s or NPP’s full name and professional designation
• Documentation must include the name of the agency that provides the service or supply
• Documentation must include the date of the original order and the date it was signed
• In the rare event that the physician or NPP fails to identify himself/herself as the order-writer, documentation must include this information: indication of the person who transcribed the order and his/her qualifications or status with the agency, and identification of the agency in relation to which the order is written
Common Verbal Order Issues
Health care institutions face myriad challenges when it comes to staff understanding and consistently following the CMS verbal order requirements. First, there is a universal misunderstanding of the difference between verbal and telephone orders. Though they are both oral orders, verbal orders are given in person whereas telephone orders are given over the phone. Second, staff are often confused by various definitions, such as who is a practitioner, what qualifies as a medical emergency, and what is a medical device. Third, staff inevitably fail to follow the verbal order rules in practice, often assuming that other practitioners will rectify problems and fix incorrect orders after the fact or that someone else will change verbal orders to signed orders.
To overcome these challenges, institutional leadership must invest time and effort to ensure all staff understand the definitions and recognize the importance of following the verbal order rules. Adequate educational materials should be given to staff and made easily accessible, particularly through electronic resources, so that the verbal order rules are top of mind. Staff should receive education regularly, as well as when new practitioners start at the institution. Leadership should also conduct regular training for staff on electronica health records (EHRs) and computerized physician order entry (CPOE) systems to demonstrate how to properly obtain, process, and correct verbal orders. Finally, institutional leadership should monitor compliance by randomly reviewing a sample of regular patient charts to identify and address any patterns of failure to follow the verbal order rules.
The Future And Recent Updates Regarding Verbal Orders
Recent changes to the CMS requirements include detailed guidance regarding telehealth and telemedicine, including the necessary documentation. In July 2019, the federal agency issued a proposed rule that would allow Medicare to reimburse patients for receiving care in their own homes under certain conditions. Additionally, CMS released additional guidance this year regarding the use of remote monitoring for certain conditions under Medicare Parts A and B (see MLN Matters 10903, Improvement Activities , and Quality Payment Program (QPP) for Clinical Psychologists (CP).). These new regulations and guidance affect how providers document interactions with patients and how telemedicine billing is coded and billed.
Providers should also keep an eye on the development of the Quality Payment Program at CMS. These regulations present updated requirements for providers, including practitioners that bill under Medicare Part B, regarding managing and documenting patient care. Most notably, these updates require various new documentation, attestation, reporting, and retention of certain records. As new requirements are published by CMS, providers need to be prepared to implement new processes to ensure accurate documentation of verbal orders and subsequent patient care.