This form helps hospitals elicit information from physicians to ensure surgery is performed in the correct status, said Ronald Hirsch, M.D., vice president of R1 RCM.[1] Contact him at rhirsch@r1rcm.com.
You Need to Know What Surgery Is Planned – Words and CPT Code!
Consent to Read: (please spell out complete surgery with no abbreviations, specify left and right)
_______________________________________________________________________________
_______________________________________________________________________________
Diagnosis:___________________________ ICD-10 Code(s): ______________________________
CPT Code(s) of planned procedure:______________, ______________, ______________
Insurance: ___________________________ Pre-Auth Number: ___________________________
Patient Status - Medicare Fee for Service Patient
_____ Day Surgery - plan discharge from recovery room
_____ Outpatient Extended Recovery - plan discharge next day, not high risk
_____ Inpatient Next Day Discharge - high-risk patient or surgery - risk factors must be outlined in documentation
_____ Inpatient - Inpatient Only List Surgery
_____ Inpatient - Expect 2+ Days In-Hospital Recovery
Discharge expected POD #2 or later - factors expected to extend in-hospital recovery must be outlined in documentation. Documentation not needed if LOS is always >2 days.
Patient Status – Other Insurers – Ordered Status Must Match Payer-Approved Status
_____ Day Surgery – plan discharge from recovery room
_____ Outpatient – Extended Recovery – plan discharge next day
_____ Inpatient
Anesthesia guidelines for medical necessity will be followed for all procedures with anesthetic.
Other Pre-admission Orders/Instructions: _____________________________________________
______________________________________________________________________________________
_____ Please initiate pre-procedure orders upon patient arrival.
Other Pre-procedure Orders/Instructions: ________________________________________
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Physician Signature: __________________________ Staff Completing Form: ___________________
Date: ________________________
