Cardiology Coding Alert

Do not ignore documentation guidelines; the physician’s signature is a mandate.

With the increasing use of electronic health records, your physician may use scribes to keep good documentation. Before implementing scribes in your practice, check payer policies. Be aware that many payers have specific rules about how the scribe process should work.

Todd Thomas, CPC, CCS-P, President of ER coder, Inc. in Edmond, OK, offers the following tips for structuring a scribe program the right way:

1. The scribe’s documentation should begin by identifying the scribe and the physician.

2. A scribe must document verbatim what is being said by the physician.

3. When using an electronic medical record, the scribe must have his or her own user name and password to access the system. Entries in the EMR must be identified as having been made by the scribe.

4. The physician must review and verify the scribe documentation and attest to its accuracy in addition to also signing the chart.

Who Can Be A Scribe?

A scribe is a person who accompanies the doctor on each patient encounter. The scriber writes or transcribes the doctor’s history taking and examination into the medical record. This helps to expedite documentation.

While it helps if the scribe has knowledge of medical terminology and a familiarity with typical encounters, procedures, and commonly used medications, there is no set training or qualification requirements since scribes basically function as a human tape recorder, says Thomas. The scribe should not independently document anything other than perhaps the review of systems and past medical, family, and social history, which Medicare documentation guidelines allow to be recorded by any ancillary staff, he adds.

Know What Medicare Says About Scribes

Before billing Medicare, be sure you’re up to speed on these scribe basics, summarized by Thomas:

• CMS does not offer any official guidance on the use of scribes, but some CMS officials have responded to direct inquiries about the use of scribes.

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

• 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 confirmation that the note accurately reflects work done by the physician.

• 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 deliver the services and create the record. When the service is in a hospital, remember there is no “incident to” billing in the hospital setting (inpatient or outpatient); thus, the scribe should be merely that, a person who writes what the physician dictates, advises Thomas. This individual should not act independently; and there is no additional payment for the use of scribes, he notes.

Documentation: Documentation should clearly state the name, title, and signature of the scribe. Additionally, you should ensure that your practitioner’s note adequately states that the practitioner performed the services documented. Your practitioner should confirm the accuracy of the services performed and should sign the records.

The Joint Commission Also Has Scribe Guidance

The Joint Commission (TJC), which accredits and certifies health care organizations, does not endorse nor prohibit the use of scribes. The Joint Commission published an updated FAQ set in July 2012 concerning the standards that apply to the use of unlicensed persons acting as scribes. TJC FAQ instructs that a scribe does not and may not act independently but can, at the direction of a physician or practitioner (Licensed Independent Practitioner, Advanced Practice Registered Nurse, or Physician Assistant), document the previously determined physician’s or practitioner’s dictation and/or other activities.

TJC surveyors will expect to see signing, timing, and dating of all entries into the medical record by the scribe, and authentication by the physician or licensed independent practitioner prior to the provider leaving the work area. In the updated FAQ, TJC does not support scribes being used to enter orders for physicians or practitioners “due to the additional risk added to the process.” Scribes also need to meet the same HIPAA and HITECH standards as other practitioners, Thomas reports.

TJC adds that if the organization determines that the scribe will be allowed to enter orders into the medical record, those orders entered into the medical record cannot be acted on until authenticated by the specific physician or licensed independent practitioner who provided the orders scribed. Authentication includes the physician signature (electronic or manual) and the date and time. TJC maintains that the authentication must take place before the physician and scribe leave the patient care area and cannot be delegated to another physician or licensed independent practitioner, warns Thomas.

Another Licensed Practitioner Acting as a Scribe? Beware

If a nurse or non-physician practitioner (NPP) such as a physician assistant (PA) or nurse practitioner (NP) acts as a scribe, the chart should clearly indicate that his documentation is entered in the record on behalf of the physician. Although there are no documented restrictions as to who can act as a scribe, some payers have expressed concern about residents or NPPs acting as scribes because of their ability to independently evaluate the patient separately from the physician and the difficulty in separating documentation performed when acting as a scribe versus documentation of services performed as a healthcare provider, Thomas warns.

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 and indicate that the note accurately reflects her work and decisions.

A Shared Service With an NPP Is Not the Same as Using a Scribe

E/M services documented by an NPP for work that is independently performed in the absence of the physician, with the physician later making rounds and reviewing and/or co-signing the notes, is not an example of a “scribe” situation.

In this case, the visit would have to be reviewed in the context of meeting the shared service requirements espoused in MCM Transmittal 1776, says Thomas. Such a service could be considered a shared service and billed under the physician’s National Provider Identifier (NPI), provided the performance and documentation requirements for split/shared visits are met, including a face-to-face encounter with the patient, he adds.

Bottom line: The physician is ultimately accountable for the documentation, and should not only sign the chart, but also indicate that the scribe’s documentation accurately reflects the work done by the physician, says Thomas.