We have been receiving an increase in questions regarding using a scribe for documentation. Below is the Medicare Part B policy for scribes.
Provider Bulletins
A scribe can be a Non-Physician Practitioner (NPP), nurse or other ancillary personnel allowed by the physician to document his/her services in the patient's medical record.
These ancillary personnel do not have to be employed by the physician or NPP performing the service in order to scribe. Scribes are most commonly used in the inpatient hospital setting, but they may be utilized in any setting.
While the physician or NPP must perform the medical service, the scribe may document what is dictated and performed in the medical record. Documentation of scribed services must clearly indicate:
- who performed the service;
- who recorded the service;
- qualifications of each person (i.e., professional degree, medical title);
- signed and dated by both the physician/NPP and scribe
When an NPP acts as a scribe for the physician, the medical record should clearly indicate the NPP is acting as a scribe. Documentation is considered to be scribed when the NPP writes notes into the medical record while the physician is personally performing the service.
Example: "I, ______, am scribing for, and in the presence of, Dr. ______"
The physician or NPP performing the service must review the information as it is written or scribed and notate his/her review of the information. The physician or NPP may add supplemental information if needed, then sign and date the information.
Example: "I, Dr. _______, personally performed the services described in this documentation, as scribed by _________in my presence, and it is both accurate and complete."
Novitas Solutions expects the use of a scribe to be clinically appropriate for each situation and in accordance with applicable state and federal laws governing the relevant professional practice, hospital bylaws and any other relevant regulations.
Incident To Services:
Evaluation & Management (E/M) Articles: Incident to Service Guidelines
Novitas Solutions Medical Review (MR) Department has observed a recent trend of the utilization of non-physician practitioners to perform initial office visits as incident to services. Documentation reviewed by the MR Department indicates that a non-physician practitioner performs the initial visit and the supervising physician documents a note in the medical record similar to the following:
"Nurse practitioner performed the history and physical and I was present for the entire encounter and my treatment plan is as follows......"
This is incorrect use of the non-physician practitioner and incorrect billing under the incident to guidelines. This article will explain the Medicare definition of incident to services and the criteria that must be met to properly bill incident to services.
CMS defines incident to services as "services or supplies are furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness."
In order to be covered as incident to the physician's service, the following criteria must be met:
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services must be an integral, although incidental, part of the physician's professional service,
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commonly rendered without charge or included in the physician's bill,
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of a type that are commonly furnished in physician's offices or clinics, and
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furnished by the physician or by auxiliary personnel under the physician's direct supervision
Incident to services must be performed under the direct supervision of the physician. CMS directs that "Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services."
CMS further indicates, under direct supervision, "This does not mean, however, that to be considered incident to, each occasion of service by auxiliary personnel (or the furnishing of a supply) need also always be the occasion of the actual rendition of a personal professional service by the physician. Such a service or supply could be considered to be incident to when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflects his/her active participation in and management of the course of treatment."
An initial history and physical performed by a non-physician practitioner, although the physician is documented as being in the room, is not covered under these guidelines. As underlined above, the physician must perform the initial service. This includes the history and physical and examination portion of the service, not only the treatment plan. Therefore, it is expected that the physician will perform the initial visit on each new patient to establish the physician-patient relationship.
Providers billing initial office visits as incident to when the initial history and physical is performed by a non-physician practitioner will have those claims denied by Novitas Medical Review.
Also note that hospital and skilled nursing facility services cannot be billed as incident to at any time. For more information and direction on incident to services, refer to CMS' Internet-Only Manual (IOM) Publication 100-02, Chapter 15, Section 60.
Posted Date: 11/22/2011
