Part B Insider (Multispecialty) Coding Alert

Published on Thu Aug 23, 2012 PDF

PAs are once again listed as 'independent practitioners' thanks to new verbiage.

The use of 'scribes' to document your practitioners' notes is commonplace in many practices--but just which clinicians are allowed to utilize help from scribes has been under fire recently. However, that policy may be more clear now that The Joint Commission (TJC) has issued a new directive on allowing physician assistants (PAs) to use scribes to record their medical notes.

Background: Previously, TJC specified that a PA was not considered an independent licensed practitioner, a requirement for being able to use scribes. This was problematic for many practices, because scribe use has been growing to speed efficiency, especially with complex electronic health records.

Compare the two versions of TJC language that follow to see the important change:

Old language: [The Joint Commission Use of Unlicensed Persons Acting as Scribes, May, 18, 2011]

Q. What is a scribe and how are they used?

A. 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 licensed independent practitioner (APRNs are considered licensed independent practitioners in some states, Physician Assistants are not considered licensed independent practitioners). It is the Joint Commission's stand that the scribe does not and may not act independently but documents the physician's or licensed independent practitioner's dictation and/or activities.

However, the new language in the revised TJC statement removes that specific restriction.

New language: [The Joint Commission Use of Unlicensed Persons Acting as Scribes, Revised | July 12, 2012]

Q. What is a scribe and how are they used?

A. 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.

Resource: The new Joint Commission document can be viewed at the following link: http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQChapterId=19&StandardsFAQId=426#.UAbQCBXYg0M.email

Scribe Role Is Similar, Regardless Of ED Provider

This is an important change for Part B practices, in which scribes also assist the non-physician practitioners. Scribes essentially support work flow and documentation for medical record coding. They are used most frequently, but not exclusively, in emergency departments where they accompany the physician or practitioner and record information into the medical record, with the goal of allowing the physician or practitioner to spend more time with the patient and have accurate documentation such as helping locate in the EHR a patients' test results and lab results.

Scribes are sometimes used in other areas of the hospital or ambulatory facility. They can be employed by the healthcare organization, the physician or practitioner or be a contracted service.

Caveat: Remember that the scribe must function as a human tape recorder and not independently document any findings of their own.