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Adding, Signing, Documenting corrections to orders

CPS, C-EMR, PM

Last Post by Anonymous 1 second ago

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watkinsd

(@watkinsd)

Posts: 21

Eminent Member

Topic starter

Can someone share with me who is adding and/or signing orders in an office visit? We currently, have a workflow that the billing Provider is responsible for adding and signing the orders within an office visit. Providers seem to think this is unnecessary work for the provider and that other staff can do that. Also, how are you documenting corrections on chart side that are made in billing? (ie: wrong diagnosis code added, wrong injection code, etc.). If changes are made in billing, we are currently appending the OV referenced to, and documenting a note that it was corrected by billing, and the provider is signing it. Any input is appreciated. Thanks

Posted : January 15, 2015 7:11 am

hbias

(@hbias)

Posts: 83

Estimable Member

you bring up a good point, the changes billing makes. However as long as the documentation supports the change, I would not think it is necessary to put the note in. I do like the idea of billing going into the chart side and doing a clinical list update to change the problem listed, as it will help prevent the wrong one being attached the next visit, especially on those code which are very close. We have billing flag the provider and scribe with coding issues so they will know the next time. We have support staff enter orders for x-ray (our techs know better what x-ray was taken than the providers) and for DME/casting- this allows who is actually doing the service to enter it. We use scribes so they enter the E&M and procedure codes directed by the physician, i.e the doctor will say add a level 3 etc.

Hilary

Posted : January 19, 2015 5:05 am

plittle

(@plittle)

Posts: 19

Eminent Member

Depending upon the provider either the provider or his credentialed Medical Assistants or nurses put in Xray, lab, orders. The providers put in their E&M codes when they do their notes. This has meant a change in workflow for some of our providers because we have had referral coordinators taking care of these types of things in the past. But since with Meaningful use it must be someone who is credentialed as a health care worker, we have had to change it. I think that our billing department will flag the provider if there is an error in the billing.

Posted : March 24, 2015 4:26 am

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