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  • Savvy Coder

    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

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    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.

    Team-Based Care

    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

    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 and