Who Signs What
Nurse Practitioner and Physician Assistant Signatures: Although talk of Physician Assistants and Nurse Practitioners being able to sign orders began several years ago, the fact remains that Physician Assistants and Nurse Practitioners cannot sign orders for any post acute care. This includes hospice, home health, nursing homes and rehab facilities. Any orders received by a Physician Assistant or Nurse Practitioner should be treated the same way that you receive orders from anyone at a physician’s office. The signature must be received by the physician supervising the practitioner prior to billing.
Nurses Signatures on the 485: The 485 asks for the Nurse’s signature and the verbal SOC date. The verbal SOC date is the Start of Care date for that episode. Many nurses, when new to writing 485’s often date their signature the day they sign their name out of habit. This can cause regulatory issues if the date of signature is after the episode is started. If there is no other recert order, this means that care has begun without physician orders. Therefore, the date on the nurses signature line should include a date that is no later than day one of the episode OR a separate recert order must be in the clinical record.
Visit Note Signatures: Visit notes should be signed by the patient whenever possible. If the patient is not able to sign a visit note, a caregiver or family member may sign. There should always be an indication of who actually signed the piece of paper. A common mistake is to see multiple patient signatures on the visit notes. This is easily misinterpreted as fraud. Lisa Selman-Holman advises that in Texas, the correct way for a caregiver to sign order is:
Patient name/your initials by permission (John Doe/jh by permission).
Alternatively, if you are not in Texas and you so prefer, caregivers can sign as such:
Julianne Haydel (caregiver) for John Doe
When creating nursing documentation, your primary goal should be to communicate relevant information about the patient in order to facilitate care between caregivers. But never forget that each and every piece of documentation in a clinical record is also a legal record. Protect yourself.
If you have any questions or comments, please feel free to leave them below in the comment section or email us at haydelcnonsulting@bellsouth.net
I was under the impression that Nurse Practioners may sign subsequent orders for their HOSPICE patients after the initial certification for terminal illness and initial plan of care have been signed by a physician. Of course, they must have a physician signature for additional certifications, but NP’s may oversee care which also means giving orders.
You are correct to a degree:) The NP may bill for services directly to Medicare Part B as an attending physician. However, the hospice itself must bill part A medicare and as such, the orders must be signed by the physician.
Physician assistants may bill for care plan oversight for hospice patients and write interim orders for home health but may not order hospice or admit a patient to home health.
In clarifying this with the American Association of Physician Assistants, it appears as though this may change with the new administration’s Medicare reform.
A good rule of thumb for now is that anytime Medicare Part A is billed, the services must be ordered by a physician.
If a patient resides in a a PCH. Family out of town. Caregivers will not sign auth for care and patient is unable. Can we accept a verbal authorization from the family with a detailed explanation as who, when, why, etc. And would this be acceptable for all required forms. If you advise yes, is there written documentation somewhere to validate this.
Thanks for your help.
Lois Smith
Landmark Home Care
Pittsburgh
Is this still accurate for a home health order? Some CMS guidelines I’ve been reviewing indicate that an NP/PA can sign a F2F. Is it now allowable for an NP/PA to sign the order as long as an MD/DO/DPM signs off on the 485? Thank you!