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A physician's order is almost always required for home health services to be provided. The Medicare program, which currently funds over one-half of the skilled home health services provided in the United States, requires all skilled services to be authorized by a physician (defined as a doctor of medicine, osteopathy, or podiatry) (DHHS, 2000). Further, the Social Security Act requires that home health providers who participate in the Medicare program must treat all patients according to the same standards (U.S. Code). As a result physician's orders are required for these agencies' non-Medicare patients as well.


Even agencies that don't participate in the Medicare program generally operate in states where professional licensure laws require that skilled services be provided only on the order of a physician, podiatrist, advance practice nurse, or physician's assistant. Therefore, it is important that home care clinicians understand regulatory requirements that dictate the format and authentication of physician's orders in the home care environment.


As was noted in a previous Signposts for Compliance column, the physician's orders provide the road map that tells clinicians how to get a home care patient from admission to discharge (Zuber, 2003). The physician's orders are truly the heart of the Medicare Plan of Care (POC). As such, they must be specific and detailed, and should include Medicare-covered services. Changes that are required in the original POC are typically secured by writing verbal orders based on a telephone conversation with the attending physician. Verbal orders must meet Medicare requirements, as well.


Disciplines and Frequencies

The physician's orders should specify:


* the discipline responsible for providing the services,


* the frequency of the services to be provided, and


* the duration of the service delivery (DHHS, 2003).



For example, if the physician wants a nurse to visit a patient three times per week for 3 weeks to provide skilled services, the frequency would be represented in the order as SN x 3/wk x 3 wk.


If the physician intends for the nurse to then reduce the frequency to two times per week for an additional 3 weeks, the frequency would be written as SN x 3/wk x 3 wk; 2/wk x 3 wk. The frequency of each discipline's visits should be specified in similar detail.



The physician's orders in the Medicare POC should also specify the exact treatments or services each discipline is expected to provide according to the required frequency. Treatment codes are available in the Medicare Home Health Agency Manual (DHHS, 2003) and can be used with the accompanying description where applicable.


Certain codes require additional descriptive detail. Particular techniques, medical supplies, durable medical equipment, or medications, when required, should be specified in the orders. For example, after the frequency detailed above, the order might read:


* for skilled observation and assessment of the patient's condition including vital signs, blood sugar, and signs and symptoms of hyperglycemia;


* or skilled observation and assessment of the Stage 3 decubitus ulcer on patient's left heel;


* for teaching the patient's wife clean dressing change using XYZ dressing on Stage 3 decubitus ulcer on patient's left heel, and


* to perform clean dressing change using XYZ dressing on patient's left heel.



As noted above, the content of the discipline-specific orders must include Medicare-covered skilled services in order for Medicare to pay for the services. Sections 205 and 206 of the Medicare Home Health Agency Manual (DHHS, 2003) provide detailed descriptions of services that are covered by Medicare under the home health benefit.


Use of Ranges

The Medicare program allows visit frequencies to be written in a range (e.g., two to four times per week), but expects that the upper end of the range will be the specific frequency. Movement within the specified range should be described and justified in the clinical documentation, particularly when a downward trend in frequency is reversed.


Before employing ranges, agency managers should ensure that there are no state requirements that would limit or prohibit their use. For example, the Illinois Home Health Agency Licensing Code specifies that any change in the expected frequency of home health visits must be accompanied by a physician's order (Illinois, 2003). Because the upper end of the range is considered to be the specific frequency, providers in Illinois have been cited for failure to receive an order to move to the lower end of the visit range. Such limitations can render the use of ranges impractical.


PRN Orders

Medicare also allows for the use of PRN, or "as needed" orders; however, they must include the clinical criteria that would result in a PRN visit being made. The PRN order must also specify how many PRN visits can be made before an additional order must be secured. For example, a PRN order might read:


1 SN visit PRN if patient's temperature measures more than 100[degrees] Fahrenheit.


Physician's Signatures

Medicare requires that the POC and all verbal orders applicable to the episode of care be signed by the physician who originated the order before the final claim for episode payment can be filed by the home health agency (DHHS, 2000, 2003). Medicare will accept faxed signatures or electronic signatures provided the computer system employs a system of unique identifiers with appropriate safeguards.


Many agencies use faxed signatures, but as of the date of this article, few employ a computerized clinical record system that provides access to their attending physicians. Medicare prohibits the use of signature stamps to authenticate physician orders.


As with the use of ranges, managers are advised to ensure that their approaches to securing physician signatures on POCs and verbal orders are acceptable under their state licensure laws. For example, certain licensure laws may prohibit the use of electronic signatures. Agencies should follow whichever regulation is the most restrictive.


Remaining compliant with physician orders is essential for success in the areas of professional and organizational liability, Medicare and state licensure law compliance, and assurance that everything done for the patient is coordinated with the physician.




1. Department of Health and Human Services, Centers for Medicare and Medicaid Services (DHHS). (2000). Conditions of Participation: Home Health Agencies. State operations manual. CMS Publication 7. Appendix B, Updated 10/00. Washington, DC: U.S. Government Printing Office. [Context Link]


2. Department of Health and Human Services, Centers for Medicare and Medicaid Services (DHHS). (2003). Medicare home health agency manual. CMS Publication 11. Sections 204.2, 205, 206, 234.7(21) and 234.9. Washington, DC: U.S. Government Printing Office. [Context Link]


3. Illinois Administrative Code. (2003). Title 77, Chapter I, Subchapter b, Part 245.50. (April 20). Available at [Context Link]


4. United States Code. (2003). Title 42, Chapter 7, Subchapter XVIII, section 1395x(o). Available at


5. Zuber, R. F. (2003). Back to basics: The Medicare plan of care. Home Healthcare Nurse, 21( 6). [Context Link]