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Attestation Documentation Reminders

Attestation Documentation Requirements

Required Scribe, Teaching Physician & NPP Attestations

Per CMS guidelines, physician involvement with scribes, residents, and NPPs (Non-Physician Practitioners) has specific documentation requirements. It is essential that the following attestations and documentation are present when NPPs, Scribes, and/or residents are utilized.

SCRIBES:

  • A scribe works side by side with the practitioner as a documentation assistant
  • A scribe cannot work independently
  • A scribe can be a:
    • Non-physician Practitioner (NPP)
    • Nurse
    • Medical Student
    • Vendor
  • Medicare requires the following documentation & attestations
    • Who performed the service
    • Who recorded the service & for whom the scribe is transcribing
    • A notation from the physician/NPP that he/ she reviewed the documentation for accuracy
    • Signed and dated by the performing physician/ NPP
  • The record must clearly delineate the scribe’s contribution to the record, i.e., “my name is XXX and I am scribing for XXXX” which should be found at the beginning of the record
  • The signature should be footnoted by a phrase that clearly states they are acting as a scribe on behalf of the provider.
  • The attending provider must review the record and include a notation that the documentation is accurate.

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TEACHING PHYSICIANS/RESIDENTS:

According to CMS, the Teaching Physician must be present during the key portion of the patient’s visit:

  • History
  • Exam
  • MDM

In order to bill for these visits, the Teaching Physician must attest to the Resident’s documentation on the above mentioned portions by documenting their own findings.

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NON PHYSICIAN PRACTITIONER (NPP)/SPLIT SHARE VISITS

  • A split/shared visit is a medically necessary encounter with a patient, where the physician and a qualified NPP (NP, PA, etc.) each personally perform a substantive portion of an E&M visit face-to-face with the same patient on the same date of service,
  • This service is NOT performed by ancillary personnel, and
  • The NPP and the Physician must be employed by, contracted with, or otherwise leased to the same entity and linked to the same entity/group/Tax ID/Medicare group number.

For Medicare:

  1. Independent NPP Services

When an NPP provides a service within the NPP scope of practice with no direct, significant physician involvement, claims submitted for such independent NPP services must show the NPP as the provider of services.

  1. Split/shared Visit

When an Inpatient NPP and MD each participate in the care of a patient; it may be permissible, in some instances, to bill Medicare Part B for the shared service using the MD as the billing provider. CMS refers to this as a “split/shared E/M service.” In order to use this mechanism for billing shared/split services, two important rules must be followed:

  • The NPP and the Physician must be employed by, contracted with, or otherwise leased to the same entity and linked to the same entity/group/Tax ID/Medicare group number.
  • The physician must perform and document a face-to-face encounter with the patient which may include documentation from at least one of the three key components (history, exam, or MDM). However, if there was no face-to-face encounter between the patient and the physician (e.g., the physician participated in the service by only reviewing the patient’s medical record), then the service may only be billed under the NPP’s name and number as an Independent NPP service.

Only if both of the above rules are met is it permissible for the NPP service to be billed using the MD’s name/number. If so, the Coder will identify the MD as the billing provider and the NPP as the assisting provider.

If both rules are not met, the NPP service must be considered an “independent service” and billed according to those regulations.

To repeat, this Split/Shared Visit Method applies only in situations where the physician and the NPP are employees of or contracted with the same group/entity/tax ID or an appropriate lease agreement exists between the entity employing/contracting with the Physician and the entity employing/contracting with the NPP. This employment/contract/leasing arrangement allows the Physician and the NPP to be enrolled with Medicare under the same entity/tax ID/Medicare group number.

When the physician and NPP are (i) employed by/contracted with the same group/entity/Tax ID (or their respective entities have entered into the appropriate leasing arrangement), (ii) enrolled in Medicare as such and (iii) the MD documents any face-to-face portion of the E/M encounter with the patient, the chart can be billed to Medicare under the physician’s billing number. It does not have to be billed under the NPP’s number.

Examples of acceptable documentation:

  • The physician may document a relevant history in the chart.
  • The physician may document a relevant examination in the chart.
  • The physician may document the Medical Decision-Making in the chart (provided there is documentation of a face-to-face encounter with the patient)
  • The physician may document a statement that attests to his or her involvement in the patient’s care. An example of such a statement could be, “I personally evaluated and examined the patient in conjunction with the NPP and agree with the management and disposition of the patient.”

Examples of unacceptable documentation:

  • Merely a signature by the physician is not acceptable for billing under the physician. While this may satisfy hospital, state, and/or federal supervision regulations it does not meet the minimum requirements for billing a shared visit to Medicare.
  • A statement of “agree with above” is not acceptable for billing under the physician.
  • In order to bill under the physician, the physician must perform and document a face-to-face encounter with the patient which may include documentation from at least one of the three key components (history, exam, or MDM).
  • If there was no face-to-face encounter between the patient and the physician (e.g., the physician participated in the service by only reviewing the patient’s medical record), then the service may only be billed under the NPP’s name and number as an Independent NPP service.

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