Can an NP or PA Function as a Scribe for a Physician?

Carolyn Buppert, MSN, JD

Disclosures

May 26, 2017

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Question

Can a Nurse Practitioner or Physician Assistant Work as a Scribe?

Response from Carolyn Buppert, MSN, JD
Healthcare attorney

Technically, the answer is yes, but why would that be practical, reasonable, or desirable? A scribe is an unlicensed individual, usually a recent college graduate who is thinking of going to medical or physician assistant (PA) school. A scribe simply takes dictation from a physician, nurse practitioner (NP), or PA. The scribe makes no medical decisions and doesn't touch patients.

I find that when I hear of NPs or PAs "scribing," it is a code word for a physician wanting to bill for medical work that an NP or PA has performed. By calling the NP or PA a scribe, the physician justifies the appropriation of the NP's or PA's work, as if the NP or PA didn't have his or her own thoughts but somehow knew what the physician was thinking, carried it out, and documented it.

Usually the physician who calls the NP or PA a scribe doesn't have the right to bill for the NP or PA's work because the physician doesn't employ the NP or PA—the hospital does. If this kind of thinking is behind the use of NPs and PAs as scribes, then it should stop. The NP's or PA's employer should be billing for the NP's or PA's services, under the NP's or PA's name.

Payers are aware of this phenomenon. Here is an excerpt from Noridian Healthcare Solutions, a Medicare Administrative Contractor[1]:

Hospital or nursing facility evaluation and management services independently performed and documented by a Non-Physician Practitioner, with the physician later making rounds, reviewing, and/or co-signing the notes, is not an example of a scribed service. Such a service must not be billed under the physician's National Provider Identifier (NPI) and does not qualify as a split/shared visit. Such a service must be billed under the NPP's name and NPI.

In the office setting, the physician's staff member, to the extent allowed by state and local law, may independently record the Past, Family and Social History (PFSH) and the Review of Systems (ROS). Such a staff member may further act as the physician's scribe, documenting the physician's words and activities during the visit. This may include the physician's review and confirmation of the PFSH and the ROS and the physician's obtaining of the Chief Complaint, History of Present Illness, examination and decision making. Under the above circumstances, scribe services may be appropriate and may help document the elements of the patient's visit to enable both completion of the clinical record and the billing of services to Medicare. Medical Scribe's services must be used and documented appropriately. The documentation must support that the physician actually performed the E/M services as billed.

Medicare guidelines say that the scribe must document, "[A]cting as a scribe for Dr X," and write "I, ___________, am scribing for, and in the presence of, Dr _______." The documentation must identify who performed the service. The physician must write and sign: "I, Dr __________, personally performed the services described in this documentation, as scribed by __________ in my presence, and it is both accurate and complete."

If all of this isn't being done, or isn't being done truthfully, then the physician is billing inappropriately.

If a physician wants to bill for a daily visit to a hospitalized patient, and an NP or PA not employed by the physician has already performed the service, then the physician will need to repeat and document the elements of service that correspond with the CPT code to be billed. If a payer (Medicare, for example) receives two bills from the same specialty, for the same patient, for services delivered on the same day, the payer will deny the claim that arrives second.

I should note that if a physician employs an NP or PA and chooses to utilize the clinician to take dictation, that's legal, although unnecessarily costly and unfulfilling for the NP or PA.

Finally, if a hospital is supplying a privately employed physician with an NP or PA and paying that clinician's salary, then that arrangement is likely a violation of the Stark laws, which limit the amount of nonmonetary compensation a hospital may provide a referring physician to $398/year. A violation of the Stark laws taints all billings associated with the violation, so both the physician's claim for payment and the hospital's bill are at risk.

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