I work for a busy podiatrist. frequently, when i code for a Avulsion/Excision (phenol) there isnt a consent form attached. I've brought this to our doc and nurses' attention and they said not to worry about it. In school we were told never to file without the forms, but at my office they tell me to bill anyway. What is the ruling on this type of paperwork?
Yes it does matter! Lack of informed consent may possibly be considered any of the following, misconduct, crime, medical malpractice, negligence or battery. The concept of using an informed consent began around 1972, in 1992, the U.S. Supreme Court ruled that informed consent laws are constitutional. You can find the Common Rule (Federal regulations governing informed consent) at 45 C.F.R. Part 46 (Subpart A). The process of the informed consent must also be documented including the risks and options have been explained and the patient understood.
Consent must be obtained prior to any procedure or intervention that is defined as invasive or minimally invasive. An informed consent gives adequate information to make the patient aware and informed of the risks, benefits and alternative treatment. An informed consent has everything to do with patient’s rights as well as an ethical principal. No one has a right to treat or act without permission, if done so can be classified as “battery”. So yes, an informed consent should be obtained for anything other than a physical examination
Check out this article by the Joint Commission. https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_Twenty-One_February_2016.pdf