# NPP's Acting as a Scribe



## kte01a

Are there any specific CMS guidelines specifying what language needs to be used when a NPP is acting as a scribe for the billing physician.  It is easy to document this during dictation ("this is PA/NP ..... dictating for Dr ....."), but what about for handwritten office and inpatient progress notes?


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## RebeccaWoodward*

This is my carriers policy.....

*Non-Physicians Acting as Scribes for Physicians*

Recently we have noted some physicians having individuals writing notes in the medical record for them, and then merely signing the note. This may be inappropriate.

If a nurse or mid-level provider (PA, NP, CNS) acts as a scribe for the physician, the individual writing the note (or history or discharge summary, or any entry in the record) should note "written by xxxx, acting as scribe for Dr. yyy." Then, Dr. yyyy should co-sign, indicating that the note accurately reflects work and decisions made by him/her.* Note: The scribe is functioning as a “living recorder,” recording in real time the actions and words of the physician as they are done. If this is done in any other way, it is inappropriate. This should be clearly documented as noted, by both the scribe and the physician. Failure to comply with these instructions may result in denial of claims. *
It is inappropriate for an employee of the physician to round at one time and make entries in the record, and then for the physician to round several hours later and note "agree with above," unless the employee is a licensed, certified provider (PA, NP, CNS) billing Medicare for services under his/her own name and number.

Record entries made by a "scribe" should be made upon dictation by the physician, and should document clearly the level of service provided at that encounter. This requirement is no different from any other encounter documentation requirement. Medicare pays for medically necessary and reasonable services, and expects the person receiving payment to be the one delivering the services and creating the record. There is no "incident to" billing in the hospital setting (in-patient or out-patient). Thus, the scribe should be merely that, a person who writes what the physician dictates and does. This individual should not act independently, and there is no payment for this activity.

It is acceptable for a physician to use a scribe, but current documentation guidelines must be followed. The physician is ultimately accountable for the documentation, and should sign and note after the scribe's entry the affirmation above, that the note accurately reflects work done by the physician.


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## kte01a

What carrier has this guideline you stated above?  I am trying to find something specifically stated by CMS.  What I have found with our local Medicare intermediary (Palmetto GBA) states this:

If ancillary staff is present while the provider is gathering further information related to the patients visit (i.e. the three key components) he/she may document (scribe) what is dictated and performed by the physician or NPP. 

The provider needs to review the information as it is written, documented, recorded or scribed and write a notation that they reviewed the documentation for accuracy, add to it if supplemental information is needed, and sign their name. 

The name of the scribe must be identified in the medical records. (Note: Although not required the date of the signature should be noted.) 
Ancillary staff does not need to be employed by the physician (example hospital employee) in order to fill the ‘scribe' role. 

Where I am stuck is that the NPP's are documenting their name, and the physician is signing the documentation; however, it is not clear that the NPP acted as a scribe (the physician is noting "patient seen and examined, agree with above").

What do you think?  I appreciate the input!


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## LLovett

I remember Palmetto coming out with this, probably 2 years ago. I no longer have the information though. I had an example of what they expected the documentation to look like. I can't find it online at this time either.

I did find another link that states what is expected and I know it is not what I originally had from PalmettoGBA ( I was in Ohio) it is similar.

http://www.alliance1.org/conferences/National2008/materials/medicaid/Medicare_Document.pdf

"Scribing
If a nurse or non-physician practitioner (PA, NP) acts as a scribe for the physician, the individual
writing the note (or history or discharge summary, or any entry in the record) should note “written
by xxxx, acting as scribe for Dr. yyyy.” Then, Dr. yyyy should co-sign, indicating that the note
accurately reflects work and decisions made by him/her."

Laura, CPC, CEMC


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## RebeccaWoodward*

kte01a said:


> What carrier has this guideline you stated above?  I am trying to find something specifically stated by CMS.  What I have found with our local Medicare intermediary (Palmetto GBA) states this:
> 
> If ancillary staff is present while the provider is gathering further information related to the patients visit (i.e. the three key components) he/she may document (scribe) what is dictated and performed by the physician or NPP.
> 
> The provider needs to review the information as it is written, documented, recorded or scribed and write a notation that they reviewed the documentation for accuracy, add to it if supplemental information is needed, and sign their name.
> 
> The name of the scribe must be identified in the medical records. (Note: Although not required the date of the signature should be noted.)
> Ancillary staff does not need to be employed by the physician (example hospital employee) in order to fill the ‘scribe’ role.
> 
> Where I am stuck is that the NPP's are documenting their name, and the physician is signing the documentation; however, it is not clear that the NPP acted as a scribe (the physician is noting "patient seen and examined, agree with above").
> 
> What do you think?  I appreciate the input!



My carrier is Cigna Govenment services.

CMS stand on this is found in most carriers general rules, past Open Door recordings and in information sent out by AAMC. 'Scribing' is allowed but it truly must be 'scribing'. To truly be 'scribing' the 'scribe' (NPP, Nurse, Transcriptionist) must do nothing but write the exact words the Doc spoke (be a walking Dictaphone). No observation or information the 'scribe' saw. The note must be identified as being done by a 'scribe'. The 'scribe must be identified and certified that s/he is only 'scribing' and both must sign and date the note. "Scribing" becomes an issue when the NPP adds in his/her observations and/or the Doc just lets the 'scribe' write what the 'scribe' saw. 

Personally, I would be extremely uncomfortable with your providers statement.


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## kte01a

I appreciate the responses!  Thanks!


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## judysoffice@mylink.net

*scribe signature*

Rebecca,

are you able to give me a link to the cigna page that indicates the scribe signature is required?

my doc and hospital want something in writing even though to me it makes sense for the scribe to sign their work.


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## RebeccaWoodward*

judysoffice@mylink.net said:


> Rebecca,
> 
> are you able to give me a link to the cigna page that indicates the scribe signature is required?
> 
> my doc and hospital want something in writing even though to me it makes sense for the scribe to sign their work.



"If a nurse or mid-level provider (PA, NP, CNS) acts as a scribe for the physician, the individual writing the note (or history or discharge summary, or any entry in the record) should note "written by xxxx, acting as scribe for Dr. yyy." Then, Dr. yyyy should co-sign, indicating that the note accurately reflects work and decisions made by him/her."

http://www.cignagovernmentservices.com/partb/pubs/mb/2001/01_5/forall/b0105b13d.html


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## sparkles1077

Here is the description of scribed services and documentation from Trailblazer Health Incident to Manual which was updated november 2010 http://www.trailblazerhealth.com/Tools/SearchSite.aspx?DomainID=1:

SCRIBED SERVICES
Documentation is considered to be scribed when a nurse, Non-Physician Practitioner (NPP) or other employee writes notes in the medical record while the physician is personally performing the service. The documentation must clearly identify the provider who performed the service to determine the appropriate payment for the service.
Scribed services may be performed in any setting; however, they are most commonly found in the inpatient setting. TrailBlazer expects that the use of a scribe be clinically appropriate to the situation. For instance, it would be highly unusual to see a scribe used to document major surgery or psychiatric counseling sessions.

When a nurse, NPP or other employee acts as a scribe for a physician, the medical record should clearly document the NPP is acting as a scribe for the physician and be signed by both the “scribe” and the physician. Please see the example below:
An NP is on rounds with a physician. Both the physician and the NP are at the patient's bedside. The physician takes a pertinent history, performs the examination and provides any patient/family education.

The NP writes the progress note and any orders in the patient's chart per the physician's direction. The NP includes in the note a statement such as, “Rebecca Jones, NP, scribing for Dr. Smith.” The note would be signed by Rebecca Jones and Dr. Smith.
In the above scenario, the service is clearly being performed by the physician, although the progress note was not documented by him and would be reimbursable at 100 percent of the physician's fee schedule.

Diana, CPC
Auditor at Private


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## sparkles1077

Here is another interesting reference that describes the hospital situation between NPs and MDs  http://www.wpsmedicare.com/part_b/departments/medical_review/2009_1221_scribes.shtml:

Guidelines for the Use of Scribes in Medical Record Documentation
"Scribe" situations are those in which the physician utilizes the services of his, or her, staff to document work performed by that physician, in either an office or a facility setting. In Evaluation and Management (E/M) services, surgical, and other such encounters, the "scribe" does not act independently, but simply documents the physician's dictation and/or activities during the visit. The physician who receives the payment for the services is expected to be the person delivering the services and creating the record, which is simply "scribed" by another person. 

Physicians using the services of a "scribe" must adhere to the following:

E/M guidelines for the place of service of that visit. According to the Centers for Medicare & Medicaid Services (CMS) Internet-only Manual, (IOM), Publication 100-04, Chapter 12, Section 30.6.1. 
Documentation supports both the medical necessity of the level of service billed and the level of the Key Components required of the service in the 1995 E/M Guidelines or the 1997 E/M Guidelines (whichever is applicable). 
Documentation meets the Current Procedural Terminology (CPT) definition of the level of E/M billed. 
Record entry notes the name of the person "acting as a scribe for Dr. X." 
Physician co-signs the note indicating the note is an accurate record of both his/her words and actions during that visit. 
*Hospital or nursing facility E/M services documented by a Non-Physician Practitioner (NPP) for work that is independently performed by that NPP, with the physician later making rounds and reviewing and/or co-signing the notes, is not an example of a "scribe" situation. Such a service cannot be billed under the physician's National Provider Identifier (NPI), since it would not qualify as a split/shared visit. Neither would it qualify as "incident to," which is not applicable in a facility setting. In this case, the service should be billed under the NPP's name and NPI.*In the office setting, the physician's staff member may independently record the Past, Family and Social History (PFSH) and the Review of Systems (ROS), and may act as the physician's "scribe," simply documenting the physician's words and activities during the visit. The physician may count that work toward the final level of service billed. However, in the same setting, an NPP accomplishing not only the PFSH and ROS, but the entire visit, should report those services under his or her own PTAN, unless "incident to" guidelines have been met (see IOM 100-02, Chapter 15, Section 60.2). Only when the "incident to" guidelines have been met, should the physician's name and NPI be used to bill Medicare for that service.

Under the above circumstances, "scribe" situations are appropriate and can be a part of the physician's billing of services to Medicare. It is important, however, to be certain that the "scribe's" services are used and documented appropriately, and that the documentation is present in the medical record to support that the physician actually performed the E/M service at the level billed.


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## eva4ever

*NPPs dictating for the MD*

This is a bit of a twist on the past conversation...

Can the physician document his/her visit on paper and then have the NPP dictate it?  The physician would then review the transcription and sign it.  If this is done, does there need to be some sort of notation accompanying the transcription that it was dictated by someone other than the physician?

Thanks!


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