Using PAs and NPs as Scribes

Question:

Our group is really having a difficult time getting all of the medical record information into the computer. Is it okay to use our PAs and NPs as scribes when they have some down time?

Answer:

We certainly understand your frustration with inputting data in to the EMR. The question you ask is rather complex and will take a bit of homework for your group to determine if this is the best use of an allied health professional. A scribe in the medical office is just like a court reporter.  They may only document exactly what is stated by the physician or NPP during the encounter and just like a court reporter; they don’t get to ask any Question:s. You may not combine the work of a PA/NP when they are acting as a scribe with that of a physician and bill it under the MD’s NPI. The practitioner who bills for the services is expected to be the person delivering the services and creating the record, which is simply recorded by another person/the scribe. Finally, the record should be signed by both parties (the scribe and the physicians) attesting to their role in the creation of the record. The practitioner must attest to having independently performed the service and agree with the information as documented by the scribe. A PA/NP who performs part of the encounter for a patient (e.g. history) and then “scribes” the remainder of the encounter is not functioning as a scribe.

For more clarity on the issue, CGS Medicare updated their guidance article recently.  Located here:

http://www.cgsmedicare.com/partb/pubs/news/2012/0412/cope18560.html

In part it states:

Record entries made by a “scribe” should be made upon dictation by the physician, and should document clearly the level of service provided at that encounter. It is inappropriate for the scribe to see the patient separately from the physician and make entries in the record unless the employee is a licensed, certified NPP billing Medicare for services under the NPP name and number.

Medicare pays for medically necessary and reasonable services, and expects the person receiving payment to be the one delivering the services and creating the record. There is no “incident to” billing in the hospital setting (in-patient or out-patient). Thus, the scribe should be merely that, a person who writes what the physician dictates and does. This individual should not act independently, and there is no payment for this activity. The physician is ultimately accountable for the documentation, and should sign and note after the scribe’s entry, that the note accurately reflects the work done by the physician, which is reflected in the affirmation above.

*This response is based on the best information available as of 05/25/17.

Intervertebral Device 22853

Question:

I code for a neurosurgeon and he insists that I bill the cage code, 22853, for each interspace.  However, the CPT book lists as cage(s) therefore our thinking is that no matter how many are placed this code is only allowed one time per surgery.  His note states “C3-C4, C4-C5, C5-C6 anterior cervical interbody fusion using PEEK interbody spacers.”  So is it 22853 x 1 unit or 22853 x 3 units?

Answer:

Your neurosurgeon is correct. CPT code 22853 is reported per interspace to describe intervertebral biomechanical devices, including PEEK cages. The term is both single or plural, “cage(s)”, because sometimes there are two devices placed at a single spinal level.

*This response is based on the best information available as of 05/25/17.

Total Thyroidectomy and Reimplantation of Parathyroids

Question:

My doctor did a total thyroidectomy and reimplanted one of the parathyroid glands into the sternocleidomastoid muscle. Can I code 60512 in addition to 60240?

Answer:

CPT 60240 for the total thyroidectomy is correct. However, if one or more of the parathyroid glands is reimplanted in the same surgical exposure (e.g., SCM muscle) then it is not accurate to separately code +60512. The reimplantation should be done through a separate surgical approach/incision for +60512.

*This response is based on the best information available as of 05/25/17.

Coding a Vena Cava Thrombectomy with a Urologist Co-Surgeon

Question:

A urologist asked me to clear the thrombus and repair the vena cava during a radical nephrectomy for tumor resection. What code should I use?

Answer:

In this case, you are acting as a co-surgeon on code 50230, nephrectomy, including partial ureterectomy, any open approach, including rib resection; radical with regional lymphadenectomy and/or vena cava thrombectomy. You will report 50230-62 and the urologist will also report 50230-62. Note that if either surgeon also performs a lymphadenectomy, that is also included in 50230.

*This response is based on the best information available as of 05/25/17.

Billing for Pre-Op H&P Visit

Question:

Hospitals require that we do an H&P within 30 days of taking a patient to the OR. If this visit is more than 48 hours prior to surgery, is that a billable visit?

Answer:

No, the H&P in this case is not a billable visit.  This question comes up often and was addressed by AMA CPT Assistant in the following excerpt:

“If the decision for surgery occurs the day of or before the major procedure and includes the preoperative evaluation and management (E/M) services, then this visit is separately reportable. Modifier 57, Decision for Surgery, is appended to the E/M code to indicate this is the decision-making service, not the history and physical (H&P) alone. If the surgeon sees the patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H&P, and this service occurs in the interval between the decision-making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days or 2 weeks) the visit is not separately billable as it is included in the surgical package. Example: The surgeon sees the patient on March 1 and makes a decision for surgery. Surgery is scheduled for April 1. The patient returns to the office on March 27 for the H&P, consent signing, and to ask and clarify additional Question:s. The visit on March 27 is not billable, as it is the preoperative H&P visit and is included in the surgical package.”

Source: AMA CPT Assistant, May 2008/Volume 19, Issue 5, pp. 9, 11

CPT says once the decision is made to proceed with surgery the subsequent visits related to the procedure (e.g., doing H&P, getting consent form signed, answering Question:s) are included.  However, in some cases a patient may be a candidate for a surgical procedure but has a number of medical issues (such as cardiac disease and asthma) that require a medical evaluation to determine if he/she is healthy enough for surgery.  After the patient has had a “medical clearance” he/she returns to you to review the medical doctor’s evaluation and you at that point decide to proceed with surgery.  This visit can be billed as an E&M visit as the decision for surgery is just now being made.

*This response is based on the best information available as of 04/27/17.

Corpectomy Denial

Question:

We submitted an op note at the request of a payer (not Medicare) and they denied the corpectomy code we billed, 63081 with the fusion code, saying the documentation doesn’t support it.  Instead, they paid us for 22551. I don’t understand this because my neurosurgeon’s operative note says he did a corpectomy.

Answer:

Ah, but does the operative note specifically state he removed at least 50% of the cervical vertebral body – or that he did a total corpectomy – to justify using a corpectomy code. I suspect not which is why the payer “downcoded” 63081 and the fusion code to the anterior cervical decompression/discectomy and fusion code, 22551.

CPT guidelines specifically state that at least 50% of the cervical vertebral body must be removed to support using a corpectomy code. Recently, Cigna released guidance that says: “A targeted subset of cervical vertebral corpectomy claims billed with CPT codes 63081 and 63082, and where abuse is probable, will be pended. The operative report will then be reviewed before reimbursement to determine if the corpectomy criterion is met. If it is not met, the claim will be denied.”

The point is that the percentage of the vertebral body removed must be documented in the operative note to justify reporting a corpectomy code.

*This response is based on the best information available as of 04/27/17.