Wiki PA/Physician Billing

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tfischer

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We have recently updated to an Electronic Health Record. At times, the physician will perform the full encounter of the patient, but the Physician Assistant is present and is ONLY scribing for the physician. Since the PA is scribing, the author shows under the PA's name, but the physician still co-signs.

My questions is, we should be billing under the physician since he/she is performing the encounter right? BUT, wouldn't the author need to be under the physicians name? Or, since the physician is co-signing, is this okay to bill under the physician?

Please HELP!! :)

Thank you!
 
A scribed note must accurately reflect the service provided on a specific date of service. The billing provider is ultimately responsible for the content of a scribed note.

A scribe's entry can be hand-written, dictated or created/typed in an electronic medical record (EMR).

Documentation of a scribed service must include the following elements:
o A personal, dated note from the scribe that:

i. Identifies them as the scriber of the service

ii. Attests that the notes are written/recorded contemporaneously in the presence of the physician performing the service

iii. Identifies the physician

o Signature of the scribe

o Co-signature of the billing physician


Example of a compliant scribe statement – “I (scribe's name) am personally taking down the notes in the presence of Dr. (physician's name).”


Individuals can only create a scribe note in an EMR if they have a password/access to the EMR. Documents scribed in the EMR must clearly identify the scribe's identity and authorship of the document – in both the document and the audit trail.
 
One other thing. The username/password must be assigned to the scribe.
For the purposes of the electronic audit trail it matters not what name appears on the note. What matters is who signed in and created it. So be careful that each individual has their own unique identifiers and do not let multiple people in under one universal username/password
 
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