Physician Signature Requirements

May 20, 2013
Rick Gawenda

First Coast Service Options, Inc., a Medicare Administrative Contractor, has put together a nice slide presentation on appropriate physician signatures in the medical records. This would also be applicable for therapists and assistants. Even though this was done by First Coast, the requirements are CMS requirements, hence, this presentation would be applicable for all providers in all states.

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This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.

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  1. Rick,
    is the term “order” appropriate in this context? As physical therapists, thus licensed professionals, we routinely receive “orders” from physicians, physician assistants and nurse practitioners requesting evaluation and treatment of various conditions. In my opinion holding a PT license implies that the therapist will evaluate the need for skilled physical therapy services and ultimately will or will not provide such services based on his/her revision of the case and subsequent clinical exam. Based on this I believe the term “referral” is more appropriate than “order”.

    Do you agree with this or do you feel the term “order” is correct in this context?

    Thank you

    1. The Centers for Medicare and Medicaid Services uses the word “order” when discussing outpatient therapy services. There are also commercial insurance carriers that also use “order” when discussing therapy services.