8/28/2014. Compliance and Practical Challenges When Using Scribes: Just What the Doctor Ordered? Objectives of the Presentation

Transcription

1 Compliance and Practical Challenges When Using Scribes: Just What the Doctor Ordered? Jerry Williamson MD. MJ. CHC. LHRM Objectives of the Presentation Definition of a Scribe Duties of a Scribe Regulatory and Certification Recommendations Provider Responsibilities for the New Member of the Team History of Scribes: Ancient History: The Ancient Egyptian scribe or sekhau, was a person educated in the arts of writing using both hieroglyphics and hieratic scripts. Sons of scribes were brought up in the same scribal tradition, sent to school and, upon entering the civil service, inherited their fathers' positions. Scribes were also considered part of the royal court and did not have to pay tax or join the military. Scribes in Ancient Israel, as in most of the ancient world, were distinguished professionals who could exercise functions we would associate with lawyers, government ministers, judges, or even financiers, as early as the 11th century BCE. Some scribes copied documents, but this was not necessarily part of their job. Wikipedia: 1

2 Definition A scribe is an unlicensed person hired to enter information into the electronic medical record (EMR) or chart at the direction of a physician or practitioner (Licensed Independent Practitioner, Advanced Practice Registered Nurse or Physician Assistant). It is the Joint Commission s stand that the scribe does not and may not act independently but can document the previously determined physician s or practitioner s dictation and/or activities. Joint Commission Background of Scribes: Licensed Professionals: Rn s, LPN s, Medical Assistants* Unlicensed Professionals: College Pre Medical Students, Medical Students, Medical Residents. *See state law. Duties and Responsibilities Record information in the medical record. Locating information such as laboratory, radiology, and other test results. Retrieve past medical records. Document when consultants were called and returned the call. Enter discharge information and instructions as dictated by the physician. Do not act independently. Dual roles. Support the work flow. 2

3 Joint Commission Standards for Scribes A job description that recognizes the unlicensed status and clearly defines the qualifications and extent of the responsibilities (HR , HR ) Orientation and training specific to the organization and role (HR , HR ) Competency assessment and performance evaluations (HR , HR ) If the scribe is employed by the physician all non employee HR standards also apply (HR EP 7, HR EP 5) If the scribe is provided through a contract then the contract standard also applies (LD ) Scribes must meet all information management, HIPAA, HITECH, confidentiality and patient rights standards as do other hospital personnel (IM ,IM , IM , RI ) Joint Commission Compliance with the Record and Provision of Care: Signing (including name and title), dating of all entries into the medical record electronic or manual (RC and RC ). For those organizations that use Joint Commission accreditation for deemed status purposes, the timing of entries is also required. The role and signature of the scribe must be clearly identifiable and distinguishable from that of the physician or licensed independent practitioner or other staff. The physician or practitioner must then authenticate the entry by signing, dating and timing (for deemed status purposes) it. The scribe cannot enter the date and time for the physician or practitioner. (RC and RC ). Joint Commission (cont d) Although allowed in other situations, a physician or practitioner signature stamp is not permitted for use in the authentication of scribed entries the physician or practitioner must actually sign or authenticate through the clinical information system. (RC ). The authentication must take place before the physician or practitioner and scribe leave the patient care area since other practitioners may be using the documentation to inform their decisions regarding care, treatment and services. (RC and RC ) Authentication cannot be delegated to another physician or practitioner. The organization implements a performance improvement process to ensure that the scribe is not acting outside of his/her job description, that authentication is occurring as required and that no orders are being entered into the medical record by scribes. (RC ) 3

4 Authentication of the Record Documentation of scribed services should specify who performed the service and who recorded the service. The scribe's note should include: The name, title, and signature of the scribe. The name, title, and signature of the practitioner providing the service. The practitioner's note should indicate: Verification the practitioner personally performed the services documented in the medical record. Confirmation he/she reviewed and confirmed the accuracy of the information in the medical record. Acceptable practitioner signature. Sample Attestations: Scribe: The documentation for this encounter was entered by (Name of Scribe) acting as scribe for Dr./PA/NP (Name of Clinician) Signature of Scribe. Date and Time. Clinician: "The documentation recorded by (Name of Scribe) the scribe, accurately and completely reflects the service(s) I personally performed and the decisions made by me." (Clinician s Name) Signature, Date, and Time. CMS Guidelines Services of a scribe are not separately reimbursable. Evidence that the practitioner reviewed and confirmed what is transcribed by the scribe. 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. A scribe does not need to be employed by the practitioner (e.g., hospital employee). 4

5 42 CFR (c) Condition of participation: Medical record services (c) Standard: Content of record. The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient's progress and response to medications and services. (1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. (2) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope ofpractice laws, hospital policies, and medical staff bylaws, rules, and regulations. CMS Transmittal 465 On May 17, 2013, the Centers for Medicare and Medicaid Services ( CMS ) published Change Request 8219 (Transmittal 465) ( CR 8219 ) announcing new guidance on the use of rubber stamp signatures. For medical review purposes, Medicare requires providers to authenticate services provided or ordered with a handwritten or electronic signature. Currently, CMS does not accept rubber stamp signatures as a method for authenticating provider orders and services, and failure to provide the appropriate authentication can be a basis for payment denial. CMS Transmittal 465 Effective June 18, 2013, physically disabled providers will be permitted to affix a rubber stamp signature to a medical record entry if the disabled provider can provide proof to CMS of the provider s inability to sign his or her signature due to the disability. This rubber stamp signature will certify that the author has reviewed the document. Medicare requires all services provided/ordered to be authenticated by the author. The permitted methods of authentication are a handwritten signature or an electronic signature. 5

6 The Four Exceptions to the Signature Requirements Facsimiles of original written or electronic signatures are acceptable for the certification of terminal illness for hospice. Some orders, for example orders for some clinical diagnostic tests, do not need to be signed. However, if these orders are not signed, there must be medical record documentation clearly indicating the physician s intent that the test be performed. This documentation must be authenticated by the prescribing physician via a handwritten or electronic signature. Other regulations and CMS instructions regarding conditions of payment related to signatures take precedence. If a regulation, National or Local Coverage Determination ( NCD or LCD, respectively) or CMS manuals are silent on whether a signature must be legible or present and the signature is illegible or missing, an audit contractor reviewing a medical record is instructed to follow the signature guidelines, excerpted from the MPIM immediately below, to determine the identity and professional credentials of the signator. For example, in cases where a signature is illegible or missing, the submission of a signature log or attestation statement may cure the signature noncompliance. If the relevant regulation, NCD, LCD and CMS manuals have specific signature requirements, those signature requirements trump other guidance. Medicare Guidelines: Novitas Solutions Inc. Issued: August 16, 2011 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. Novitas Solutions Guidelines Continued 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. 6

7 Cahaba Government Benefit Administrators Guidelines for the Use of Scribes in Medical Record Documentation Reminder Posted April 11, 2013 in Part A/B Physicians may occasionally utilize the services of a scribe to assist with documentation during a clinical encounter, which can be in an office or a facility setting, between the physician and the patient. 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. The scribe does not act independently in Evaluation and Management (E/M) services, surgical, and other such encounters, but documents the physician s dictation and/or activities during the visit. The physician who receives the payment for the services is expected to be the person delivering the services and creating the record, which is simply scribed by another person. Cahaba Continued Documentation of scribed services must include the following: Who performed the service; Physician co signs the note indicating the note is an accurate record of both his/her words and actions during that visit Example: I, Dr., personally performed the services described in this documentation, as scribed by in my presence, and it is both accurate and complete. Who recorded the service; Record entry notes the name of the person acting as a scribe for Dr. X. Example: I,, am scribing for, and in the presence of, Dr.. Qualifications of each person. Signed and dated by both the physician and the scribe. Cahaba Continued: Hospital or nursing facility evaluation and management services documented by a NPP for work that is independently performed by that NPP, with the physician later making rounds and reviewing and/or cosigning the notes, is not an example of a scribe situation. Such a service should be billed under the NPP s name and NPI since they are providing the service. In the office setting, for an evaluation and management service, the physician s staff member may independently record the Past, Family and Social History (PFSH) and the Review of Systems (ROS), and may act as the physician s scribe, simply documenting the physician s words and activities during the visit. The physician may count that work toward the final level of service billed. 7

8 Cahaba Continued Under the above circumstances, scribe situations are appropriate and can be a part of the physician s billing of services to Medicare. It is important, however, to be certain that the scribe s services are used and documented appropriately, and that the documentation is present in the medical record to support that the physician actually performed the service at the level billed. WPS Medicare J5 MAC Part B Guidelines for the Use of Scribes in Medical Record Documentation "Scribe" situations are those in which the physician utilizes the services of his, or her, staff to document work performed by that physician, in either an office or a facility setting. In Evaluation and Management (E/M) services, surgical, and other such encounters, the "scribe" does not act independently, but simply documents the physician's dictation and/or activities during the visit. The physician who receives the payment for the services is expected to be the person delivering the services and creating the record, which is simply "scribed" by another person. Physicians using the services of a "scribe" must adhere to the following: E/M guidelines for the place of service of that visit. Documentation supports both the medical necessity of the level of service billed and the level of the Key Components required of the service in the 1995 E/M Guidelines or the 1997 E/M Guidelines (whichever is applicable). Documentation meets the Current Procedural Terminology (CPT) definition of the level of E/M billed. Record entry notes the name of the person "acting as a scribe for Dr. X." Physician co signs the note indicating the note is an accurate record of both his/her words and actions during that visit. WPS Medicare J5 MAC Part B In the office setting, the physician's staff member may independently record the Past, Family and Social History (PFSH) and the Review of Systems (ROS), and may act as the physician's "scribe," simply documenting the physician's words and activities during the visit. The physician may count that work toward the final level of service billed. Under the above circumstances, "scribe" situations are appropriate and can be a part of the physician's billing of services to Medicare. It is important, however, to be certain that the "scribe's" services are used and documented appropriately, and that the documentation is present in the medical record to support that the physician actually performed the E/M service at the level billed. 8

9 Meaningful Use CPOE Documentation Requirements: Who can enter medication orders in order to meet the measure for the computerized provider order entry (CPOE) meaningful use objective under the Medicare and Medicaid EHR incentive programs, and when must these medication orders be entered? CMS FAQ CMS FAQ Response: Any licensed healthcare professional can enter orders into the medical record for purposes of including the order in the numerator for the measure of the CPOE objective if they can enter the order per state, local, and professional guidelines. The order must be entered by someone who could exercise clinical judgment in the case that the entry generates any alerts about possible interactions or other clinical decision support aides. This necessitates that CPOE occurs when the order first becomes part of the patient's medical record and before any action can be taken on the order. Each provider will have to evaluate on a case by case basis whether a given situation is entered according to state, local, and professional guidelines, allows for clinical judgment before the medication is given, and is the first time the order becomes part of the patient's medical record. Stage 2 Eligible Professional Meaningful Use Core Measures Measure 1 of 17 Date issued: October, 2012 CPOE for Medication, Laboratory and Radiology Orders Objective Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines. Measure More than 60 percent of medication, 30 percent of laboratory, and 30 percent of radiology orders created by the EP during the EHR reporting period are recorded using CPOE. Exclusion Any EP who writes fewer than 100 medication, radiology, or laboratory orders during the EHR reporting period. 9

10 Potential Benefits of a Scribe: Face to face care that increases both patient and provider satisfaction. Reduces provider documentation time during the encounter. May improve the overall quality of documentation. Provider efficiency and productivity may increase. Real time availability of the documentation. Challenges When Using a Scribe: Potentially reduce patient s willingness to provide the clinician with all pertinent information. Workflows will need to be redefined. Provider verification & authentication of scribed documentation may slow down workflow. Documentation errors by scribe. Provider not reviewing scribed entries for accuracy prior to authentication. May not generate additional revenue. Managing and Monitoring Scribes: Documentation guidelines Authentication guidelines Regulations and guidance Minimum knowledge, experience, and education qualifications Definition of roles (i.e.. Scribe vs. provider) Responsibilities and clear scope of practice Performance expectation (i.e. productivity) Continuous training Sanctions Documentation auditing protocols Privacy and security auditing protocols Certification and/or licensure AHIMA: Using Medical Scribes in a Physician Practice (Body of Knowledge) 10

11 Implementing a Scribe Program Program goals State scribe roles & responsibilities Patient communication Examination room arrangement Ongoing evaluation of the program Provider commitment Thank You: Q&A 11