How to Bill for Scribes, Technicians, and Other Nonphysician Providers
By Sue Vicchrilli, COT, OCS, Academy Director of Coding and Reimbursement, Cherie McNett, Director of Health Policy, Michael X. Repka, MD, MBA, Medical Director of Health Policy, and George A. Williams, MD, Secretary for Federal Affairs
Who are NPPs? The nonphysician practitioner (NPP) is defined as anyone designated by you—the physician—to document or dictate on your behalf. This means unlicensed staff—such as scribes, technicians, and orthoptists (certified or not)—as well as licensed physician assistants and nurse practitioners.
Scribes, Techs, and Orthoptists
Tests. Well-trained, scribes, techs, and orthoptists can perform tests with a technical (–TC) component, provided that these steps are taken.
- The physician evaluates the patient and determines what tests are necessary.
- An order is written that includes the type of test and which eye(s) should undergo testing. With a verbal order from the physician, staff may document the physician’s delegated order.
- The medical record reflects the medical necessity for the tests.
- The physician promptly provides the interpretation of the test.
E&M services. Techs and orthoptists may perform one level of established patient exam following a physician order that details what elements of the exam are medically necessary. The technician code (CPT code 99211) has this description: Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. To learn more, read “When Techs See Patients” (Savvy Coder, October 2007).
Since April 2003, the National Correct Coding Initiative (CCI) has bundled all tests with exam level 99211.
Signature. Because billing is under the ordering physician’s National Provider Indicator (NPI), the physician must be on site and sign the exam note.
Earlier this year, CMS updated its guidance on signature requirements. CMS Transmittal 713 described the new policy, which came into effect on June 6, 2017, as follows: “Scribes [and technicians and orthoptists] are not providers of items or services. When a scribe is used by a provider in documenting medical record entries (e.g., progress notes), CMS does not require the scribe to sign/date the documentation. The treating physician’s/NPP’s signature on a note indicates that the physician/NPP affirms the note adequately documents the care provided. Reviewers are only required to look for the signature (and date) of the treating physician/NPP on the note. Reviewers shall not deny claims for items or services because a scribe has not signed/dated a note.”
While physicians are required to provide an attestation statement, CMS doesn’t instruct physicians to use a specific form or format for that attestation, but the agency indicates that the following example is acceptable: “I, [print full name of the physician/practitioner], hereby attest that the medical record entry for [date of service] accurately reflects signatures/notations that I made in my capacity as [insert provider credentials, e.g., M.D.] when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate, and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”
Physician Assistants (PA) and Nurse Practitioners (NP)
Licensing. PAs and NPs are licensed, and they must maintain education credits as their state licensure requires. Like physicians, they must enroll—and re-enroll every 3 to 5 years—in Medicare and with commercial insurances.
Billing and NPIs. PAs and NPs can bill services for established patients under their own National Provider Identifier (NPI); in this instance, payment would typically be 85% of the physician allowable. Alternatively, they can bill under the physician’s NPI with the full fee schedule allowable. CMS Transmittal 178 specifies that the service provided must be medically necessary and the service must be within the scope of practice for an NPP in the state in which he or she practices.
The H&P exam. In 2009, when CMS mandated that a history and physical (H&P) exam be performed on every patient undergoing a surgical procedure, some high surgical volume practices hired a PA or NP to perform this service, and claims were submitted independently from the physician’s NPI.
PAs and NPs are exempt from the deactivation rule. Good news. According to MLN Matters SE1034, PAs and NPs are excluded from the process that would deactivate them for inactivity if they don’t submit a claim under their own NPI for 12 months.
As team-based care becomes increasingly important in ophthalmology, it is critical to know the relevant rules and regulations regarding NPPs.
MIPS—Jan. 15 Deadline for IRIS Registry Users
MIPS reporting. The IRIS Registry is a one-stop shop for the Merit-Based Incentive Payment System (MIPS). Use it to report MIPS’ quality measures, advancing care information (ACI) measures, and improvement activities.
Finish entering your MIPS information into the IRIS Registry web portal by Jan. 15, 2018. This deadline applies to ACI attestation, improvement activities attestation, and—if you haven’t integrated your electronic health record (EHR) system with the IRIS Registry—reporting of quality measures. If you have integrated your EHR system with the IRIS Registry, your MIPS quality data is automatically extracted from your EHRs, but ACI measures and improvement activities must be reported manually.
Submit a signed data-release consent form for each provider by Jan. 15, 2018. The IRIS Registry won’t submit a provider’s MIPS data to the Centers for Medicare & Medicaid Services (CMS) unless it has received the signed consent form by Jan. 15. You must submit a new consent form each year. Starting in early December, you can submit consent forms via the IRIS Registry dashboard. For instructions, see aao.org/consent-form.
What if you aren’t participating in the IRIS Registry? If you missed the deadline to sign up for the IRIS Registry, you have several other MIPS reporting options. For more information, read “MIPS—Today’s To-Do List: Avoid the Payment Penalty” (Savvy Coder, November 2017).
Learn more. See aao.org/iris-registry and aao.org/medicare.