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Question: If a clinical staff member or scribe makes entries into a patient鈥檚 medical record, can that effort be put toward a physician鈥檚 time for the purposes of leveling evaluation and management (E/M) services?

New Hampshire Subscriber

Answer: As 鈥渢ime鈥� for E/M services is supposed to be a reflection of a provider鈥檚 efforts. When someone makes an entry into an electronic medical record (EMR) but the physician doesn鈥檛 review and address the same components, too, then the efforts wouldn鈥檛 reflect time spent by the physician 鈥� because the physician didn鈥檛 spend the time.

Medicare Administrative Contractor (MAC) says it is more frequently seeing in EMRs that nursing or other medical staff are completing or updating components of E/M services.

CGS says: 鈥淚f the physician does not review and address these components as well; and the only documentation relating to these components is the entry from the nurse or a medical technician, then these components may not be used in determining the level of E&M service provided as they do not reflect the work of the physician.鈥�

Similarly, if a physician uses a scribe to record entries, then the scribe should be with the physician together with the patient and document clearly the encounter鈥檚 level of service.

Additionally, CGS says, 鈥淚t is inappropriate for the scribe to see the patient separately from the physician and make entries in the record unless the employee is a licensed, certified NPP [nonphysician practitioner] billing Medicare for services under the NPP name and number.鈥�

Using a scribe should not change payment activity. According to CGS, 鈥淭he physician is ultimately accountable for the documentation, and should sign and note after the scribe's entry, that the note accurately reflects the work done by the physician, which is reflected in the affirmation above.鈥�

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, 星空入口