question regarding physician orders

01 Mar 2019 14:33 | Anonymous member (Administrator)

Following are two questions and the response received re: physician orders.  These are provided for your reference:

  1. Do you count Ophthalmologist visit or Optometrist visits?
  2. If a podiatrist writes in his exams progress note, follow-up in 2-3 months, can this be counted as an order?


Since "Orders and Visits" items are no longer CMS required, and are now “State only”, the interpretation of order and visits would be entirely up to each individual States' RAI coordinator. 

The text below is the position of the PA State RAI Coordinator-

Only examinations by the practitioners specified in the coding instructions may be considered; and only orders written by those specified practitioners for new or altered treatment may be considered.

An instruction for when to schedule the next appointment (F/U 2-3 months for example)) is not new or altered treatment.

A consultation order to another physician in the future would also have to be for new or altered treatment, for example a consultation to start dialysis, before it could be considered.

Thank You-


Kerry S. Weaver

HC Senior Consultant


6380 Flank Drive, Suite 100

Harrisburg, PA 17112

PH 717.541.1203

PH 800.359.1203

FX 717.541.1206
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