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split/sharted

Joanna Posted Thu 23rd of February, 2017 21:55:21 PM
I am told that my PA and I cannot do split visits for new patients. Generally, when I see new patients, she does the HPI, I go and do the exam and discuss the A/P with the patient and she documents the findings. Our EMR has an audit trail which tracks who opens the various elements of the note and she does all the "scribing" for the exam and plan. I am told that she is just a scribe and that she can't do the HPI is used in that capacity and that new patients can not be "shared". Is this correct? This was sent to me by my office: New Patients or Consultations -Cannot be a split/shared visit. -If the NPP performs any part of the visit, they are limited to what other ancillary staff can do; the Chief Complaint, ROS and PFSH. -Alternatively, NPP can be used as a scribe; proper scribe attestations must be documented by the NPP and physician in this new patient/consult progress note.
SuperCoder Answered Tue 28th of February, 2017 01:14:24 AM

Hi,

Hope the following information proves useful for you.

  • Medicare policy is not opposed to the use of personnel as scribes. Medicare does not pay separately for the use of a scribe.The E/M service is a face-to-face encounter between the patient and the practitioner. The scribe functions as a recorder of facts and events which occur between the practitioner and the patient during the encounter.  There must be evidence that the practitioner reviewed and confirmed what is transcribed by the scribe.
  • A scribe is one who follows the practitioner around and writes word for word, what the practitioner says as he's examining the patient - a sort of human tape recorder.
  • Pursuant to the Medicare Documentation Guidelines, the only information a scribe can independently document is the ROS and PFSH elements that can be recorded by ancillary staff or taken from a form completed by the patient.
  • CMS does not prohibit Non-Physician Providers (NPP's) from using scribes.
  • Services of a scribe are not separately reimbursable.
  • A scribe does not need to be employed by the practitioner(e.g., hospital employee).
  • When a scribe enters on a paper medical record and correction is needed, the provider must add and sign an addendum to the scribe's note, rather than cross out or alter what the scribe has written.

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