PAs Should Not Be Used as Scribes

I write a lot about EHRs While EHR has been a boon towards accurate, legible documentation of the care that we provide to our patients, it has also resulted in better safety and exposed new dangers, not all of which were anticipated.

We are at the edge of a new era, but the technological skills and the abilities of the people who must manipulate the EHR daily are varied, and has resulted in a lot of difficulty, frustration and confusion. Various organizations and facilities have rushed to provide the technical assistance providers need to maintain and improve productivity, in high volume settings.

One such "solution" has been the use of scribes. These trained individuals, skilled in the usage of the EHR, help providers rapidly and accurately document the elements of the patient encounter such as medications, social history, history of the present illness, review of systems, and elements of the physical examination, as appropriate.

The provider then reviews the note, corrects it, and "signs" it electronically for permanent attachment to the patient's EHR. Scribes can improve all aspects of patient care in high-volume settings, such as the emergency department. There has been a disturbing trend recently, assigning "scribe" roles, to physician assistants (PAs).

This was discussed in an article by Tricia Marriott, PA-C, who travels the country educating healthcare organizations about PAs. In the article, she wrote that several Medicare contractors have noted "…that PAs and NPs are providing documentation in the medical record of patient encounters in which both the PA and physician appear to have participated, and add that these encounters should not be billed under the physician's NPI because they do not meet the documentation rules for the service to be billed by the physician."

Tricia added that, "If the PA has performed any of the three key components of the encounter - the history of present illness, the physical exam and/or the medical decision-making-the "`shared visit"' rules must be met in order to bill under the physician's number to the Medicare program. The moment the PA steps into the provider role and "shares" the work of the encounter with the physician, the shared-visit rules come into play, including the specific documentation requirements for the physician to meet. Unless those requirements have been met, the encounter, under Medicare rules, must be billed under the PA's NPI, with reimbursement at 85 percent of the physician fee schedule. This rule is particularly important for initial Medicare patient encounters in the office setting, because the "`incident-to"' billing guidelines also will not be met."

It is very important for physicians, and PAs to understand these billing rules, because ignorance is no defense with Medicare if a provider bills incorrectly, or fraudulently in providing services to Medicare patients. That notwithstanding, it is an exceedingly poor use of a highly trained and experienced clinician like a PA, to use that individual as a scribe.

In a recent blog, I discussed the benefits of a PA to the practice under "incident to" rules, and how to maximize the financial and productivity benefits to a practice. I made the argument to completely avoid incident to billing in the private practice setting, because it made no sense from either a productivity or financial standpoint.

I would make a similar argument regarding the utilization of PAs in every environment were PAs are being utilized in direct patient care. They need to be frontline providers on teams of physicians and other professionals, caring for patients with an appropriate level of autonomy. This makes sense from a productivity, financial, as well as a patient care standpoint. Studies have documented the safety and utility of PAs in delivering patient care in nearly every environment. Teams function best when every member of the team practices at the top of the training, experience, and license.