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Compliance Guide to Team Based Documentation

Team based documentation refers to a variety of strategies that enlist the support of well trained staff to assist in the preparation of visit documentation and in the delivery of services that commonly take place during a physician patient encounter. Participants in team based documentation may (a) gather information for the patient’s visit, (b) obtain certain types of information directly from the patient, (c) assist practitioners in navigating the electronic health record, (d) accompany the physician, (e) record information into the medical record, and (f) document the physician’s observations and activities. (Joint Commission, Standards FAQ Scribe Definition, in Human Resources (HR) (Critical Access Hospitals) (2016)). The goals of team based documentation are to improve care, increase efficiency, and enhance patient satisfaction by allowing the physician or advanced practice provider (APP) to focus more intently on the needs of the patient.

The UR Medicine Compliance program supports and encourages team based documentation. We believe these strategies will play an important role in the transformation of care from traditional fee for service delivery to patient-focused population health management. When implemented effectively, they help to reduce practitioner burnout, alleviate “click fatigue,” reduce after hour’s progress note editing and increase job satisfaction for the entire team. To the extent they improve the quality and completeness of medical documentation, they further important goals of the UR Medicine Compliance program.

Nevertheless, to ensure the safety of our patients and the proper and appropriate billing for services that are provided, these innovations need to operate within the boundaries of applicable rules and requirements.

This Guide was developed to ensure that practitioners who are interested in pursuing team based documentation are aware of the rules and requirements that must be followed when implementing this type of program. Before beginning to provide team based documentation at URMC or at any URMC Affiliate, practitioners are expected to read this Guide carefully and to agree to follow the principles set forth in this Guide and all applicable laws, regulations and billing requirements. They must also ensure that all members of their team are adequately licensed and trained to perform the responsibilities assigned to them. Last, they are responsible for ensuring that all documentation of the care provided by the team is clear, accurate and complete.

Questions that may arise about the principles set for this in this Guide or about team based documentation in general should be brought to the attention of the clinical department’s designated Compliance Analyst/Educator (at URMC/Highland) or to the Affiliate Compliance Officer. View a list of these individuals on our About Us page. It is our expectation that we will develop a series of Frequently Asked Questions which can be referred to for additional assistance.

This Guide is a work in progress. Our intention is to update it periodically to reflect changes in applicable laws, URMC policy and feedback from stakeholders. Comments and suggestions are encouraged and appreciated and may be submitted to Compliance@URMC.Rochester.edu.

Differentiating Team Based Documentation from Other Care Delivery Models

Team Based Documentation vs. Traditional Treatment and Billing Methodologies

There are a number of different ways that professional services are provided and billed at URMC and its Affiliates. The most common examples include the following:

  • Direct Billing: A physician or advanced practice provider (APP) examines a patient, provides diagnostic or therapeutic services and bills for the services provided;
  • Teaching Physician Billing: A medical resident or fellow examines or treats a patient under the supervision of a teaching physician. The teaching physician documents compliance with the applicable teaching physician rules and bills for supervising the services;
  • Shared Visit Billing: A physician in a hospital based clinic or inpatient unit shares an evaluation and management (E&M) visit with an APP, documents participation in the care provided and bills for the combined services of the physician and APP;
  • Incident To Professional Billing: A physician in an office based setting evaluates a patient enrolled in Medicare and establishes a plan of care.Subsequently, an APP provides care to the patient as part of the physician-established plan of care under the direct supervision of the physician (the physician is present in the office suite). The physician bills Medicare for the professional services.

As will be described below, team based documentation strategies are not limited to Direct Billing. They may be incorporated into any of the billing models set forth above. For example, in a primary care exception clinic, where the teaching physician is not required to see the patient for level 1-3 E&M services furnished by experienced residents, it may be the resident, not the teaching physician, who receives team support to provide the services billed by the teaching physician. Also, the APP, the physician, or both may receive team support to perform and document a visit that will be billed as Shared or Incident To by the physician. It is important to remember that team based documentation does not eliminate the specific participation, documentation or attestation requirements that must be met to use any of these billing methodologies. Nor does it relax any of the licensure or professional responsibility requirements that govern the role that each team member may play. Below we will provide more guidance on these requirements and on the use of team members in each of these strategies

Team Based Documentation vs. Scribe America Scribes

Scribe America provides trained medical scribes to certain URMFG physicians. This program may be particularly attractive to physicians who are looking for a turn-key solution to their electronic health record documentation needs. Scribe America scribes are recruited and trained by Scribe America. Typically they are recent college graduates who are interested in pursuing a career in medicine or an allied health professional. They are not required to be licensed or to have any clinical training beyond the training they receive from Scribe America. Feedback from those who work with Scribe America scribes has generally been very positive.

The contract between Scribe America and URMFG delineates the services these individuals may provide, and essentially limits their role to transcribing the billing provider’s examination and observations into eRecord. Scribes who work for Scribe America may not obtain or independently document the history, review of systems, past medical, family and social history, examination or medical decision making. That must be done by the billing practitioner.

The UR Medicine Compliance Program supports the use of Scribe America scribes as another alternative to traditional care delivery and documentation approaches. Because those services are governed by the contract between URMFG and the vendor, this Guide does not address the use of Scribe America scribes and should not be relied upon as a resource for those scribe services. Practitioners seeking to pursue contracted scribe services at URMC or Highland should contact their department administrator. They should also review URMC Ambulatory Policy No. 0.3.4, Use of Medical Scribes, which applies to the Scribe America program.

Standards That Apply to Team Based Documentation

Ambulatory Policy 0.3.5

All team based documentation services provided at URMC facilities must comply with Ambulatory Policy 0.3.5, Team Documentation. Among other requirements, the policy addresses the need for training and appropriate job descriptions for team members, as well as the importance of ensuring that all individuals on the team are acting within the scope of their licensure and privileges. The policy also makes clear that the adoption of team based approaches are subject to review and approval by the Compliance Office, and that the use of team based documentation strategies does not relieve the billing provider of his or her responsibility to comply with E&M billing rules and hospital policy for order writing.

Joint Commission Guidelines

Physicians interested in pursuing team based documentation strategies must also bear in mind that UR Medicine Hospitals are subject to Joint Commission (JC) standards which are based in part on CMS conditions of participation. JC guidance does not specifically address scribes or team based documentation, and the JC has stated that it neither endorses nor prohibits the use of these strategies. However, the JC has indicated that these approaches need to confirm to general human resource, documentation and provision of care standards, include the following:

  • Job descriptions that set forth the necessary qualifications and the individual’s responsibilities;
  • Training specific to the individual’s role;
  • Competency assessments;
  • Dated/timed electronic medical record entries which describe the role and contain the signature of the team based documenter. The entries must be clearly distinguishable from those of the physician/practitioner on whose behalf the information is being collected or the documentation is being scribed (e.g. “Scribed for Dr. Meliora by [name],[title] on [date] at [time]”);
  • Signed, timed and dated authentication entered by the physician/practitioner on whose behalf the information was obtained/scribed before the physician/practitioner leaves the clinical area.

Compliance with these expectations is important to ensure our hospitals remain in good standing with CMS and with the Joint Commission. The sections that follow will provide assistance in guidance in meeting these requirements.

Legal Considerations

When identifying the individuals who will participate in the team, it is important to consider state licensure requirements. The practice of registered nursing and licensed practical nursing, are defined by law. RNs and LPNs are limited in the clinical services they may provide by the laws applicable to their licensure category (New York Education Law 6902[1] and [2]). It is professional misconduct for LPNs, RNs or other licensed professionals to practice their profession beyond its authorized scope (New York Education Law 6509[2]). It is also professional misconduct for a physician or APP to permit an unlicensed person to perform activities requiring a license, or to delegate professional responsibilities to a person who is not qualified by training, experience or licensure to perform them. (New York Education Law Sections 6509[7], 6530[11] and [25]). Unlicensed practice of a profession is a Class E Felony. (Education Law 6512).

Non-adherence to licensure requirements may also affect entitlement to payment. Claims submitted to some government payers, such as Medicaid, include a certification by the billing provider that every person providing services, care or supplies has the “necessary licensing, certification, training and experience to perform the clinical services.” Submitting a claim to Medicare or Medicaid that does not conform to such certifications may be a violation of the State and Federal Civil False Claims Acts. Penalties for violating a Civil False Claims Act include treble damages (three times the amount incorrectly billed) plus penalties of more than $21,000 per claim.

It is beyond the scope of this Guide to provide detailed guidance regarding the activities that require a license or that fall within and without the scope of individual license categories. But it is the responsibility of the team leading practitioner to ensure, before implementing or participating in team based documentation, that the work flow of the team based model does not call upon any individual – whether licensed or unlicensed – to perform any activity he or she is not well-trained, licensed and qualified to perform. Common scope of license questions can be resolved by consulting the “Top of the License Guide” prepared by Ambulatory Care Administration. Additional information regarding the scope of practice permitted at URMC or Highland may be obtained by contacting Pat Feola, Nursing Practice Administrator at (585) 276-3041 or Patricia_Feola@urmc.rochester.edu. Guidance may also be found in the Office of the Professions section of the State Education Department website. (The website includes a detailed Practice Information page on RN and LPN practice issues.)

Anyone who identifies a situation where services furnished under a traditional or team based documentation delivery model do not meet applicable legal requirements should contact the URMC Compliance Office at (585) 275-1609. Those wishing to report concerns confidentially or anonymously may call the Integrity Hotline (585) 756-8888.

Creating the Team

Who Can Lead the Team?

The team leader is the person who submits a claim for the service being provided. The team leader must be a licensed professional practitioner with a billing credential such as a physician, a nurse practitioner or physician assistant. The team leader ensures that each participant on the team functions effectively and works within the limits of his or her licensure, qualifications and training. The team leader is responsible for identifying the payer-prescribed billing methodology the team will be using and for ensuring compliance with the care delivery, documentation and billing requirements for that methodology.

Who Can Be on the Team?

Team members can be licensed or unlicensed personnel or a mixture of both.Licensed personnel could include registered nurses or licensed practical nurses. Unlicensed personnel might include medical assistants or technicians, or students preparing for or enrolled in medical or nursing school.

If the plan is to build the team using existing nursing staff or techs, team leaders should consider the effect that adding these additional responsibilities may have upon the team members’ ability to fulfill their current clinical roles.Consideration must also be given to whether the current staff have the necessary skills to thrive in these roles. You may want to test their listening and writing skills using a simple dictation exercise.

You should also consider whether it is feasible for these individuals to obtain or scribe exam-specific information while performing their nursing or technician roles. Some physicians who have adopted team based documentation approaches at other academic medical centers have found it helpful to transition from a 1:1 to a 1:2 provider-to-nurse/technician ratio model to allow team based documentation to work effectively. More information on team structure is provided in Section d below.

Existing job classifications for team members who are registered nurses or licensed practical nurses are appropriate for individuals who hold those licenses and will be participating in team based documentation. The generic job responsibilities for those positions already encompass the activities engaged in by members of a team based documentation team. Before a team based approach is implemented, consideration should be given to addressing the individual’s functional job descriptions. These are the descriptions which are maintained by the department or clinical area and are specific to the individual’s particular job. Updating these descriptions to describe the person’s role and involvement in team based documentation helps to set clear expectations and to avoid misunderstandings.

In the case of non-licensed individuals, it is important, to comply with JC standards and for other reasons, to ensure that the individual’s job description addresses his or her team based documentation responsibilities. The Human Resources Office has developed a job code and generic job description for “Clinical Team Associates” who are unlicensed individuals who will be participating in team based documentation. Before involving individuals in a team based documentation program, Human Resources should be consulted to determine whether a job reclassification is appropriate. As with licensed individuals, attention should be paid to ensuring that the individual’s functional job description indicates the person’s role and involvement in team based documentation. This is particularly important for unlicensed persons who may have previously had other roles or responsibilities.

View a copy of the current Clinical Team Associate job description. More information on team member job descriptions at URMC may be obtained by contacting: Human Resource Business Partner Peg Lee at (585) 275-2537 or Peg_Lee@urmc.rochester.edu.

The inclusion of nurse practitioners, physician assistants and other APPs on a team requires careful evaluation. If the goal is for the APP to perform all or some elements of an E&M service which will then be billed by the physician, then each of the care, documentation and billing requirements established by Medicare and other payers for Shared Visits or Incident To Billing must be followed. Team based documentation strategies do not excuse the billing physician from meeting the minimum participation and documentation requirements for Shared Visits or for Incident To Billing. They cannot be used to permit the billing physician to delegate services to the APP that the billing physician must provide to share the visit. They cannot be used to expand Shared Billing rules to diagnostic or therapeutic procedures.

Similar considerations apply when residents or fellows participate in a team based documentation model. In order for a teaching physician to bill for the services of a resident who is working with the support of a team, the resident must perform those aspects of the service that cannot be delegated to nursing or other ancillary personnel and the teaching physician must comply with the supervision and documentation requirements set forth in the teaching physician rules.

The sections that follow provide more information about the correct use of team based strategies for shared visits and teaching physician services.

How Should Team Members Be Trained?

Team members must meet the minimum educational and/or experience qualifications applicable to their job codes. They should also be either experienced or trained in anatomy and physiology, medical terminology, medical note structure, and electronic health record navigation.

As of the date the current version of this Guide was released, URMC has not developed a centralized training program for team based documentation. Responsibility for training team members rests primarily with team leaders. However, we are planning to develop a list of Team Documentation Champions who may be able to assist you in structuring your training program.

To the extent you intend to include unlicensed members on your team, it would be prudent to consider recruiting individuals who have completed a scribe training program, passed a medical scribe competency exam or obtained certification as medical scribes.  Several organizations have developed certification programs. These include the American College of Scribe Specialists which offers the Medical Scribe Certification and Aptitude Test (MSCAT). Individuals who pass the examination are eligible to become Certified Medical Scribe Apprentices (CMSAs); individuals who pass the examination and, in addition, have completed a 50-hour clinical training program or 200 hours of unassisted clinical workload documentation are eligible to become Certified Medical Scribe Specialists (CMSSs).

Team leaders should also give careful consideration to developing a list or glossary of specific clinical terms team members will encounter in their clinical practices. Individuals who lack formal clinical training or who are new to a clinical specialty may not be familiar with the terminology used in the practice and may struggle with abbreviations, acronyms and the crosswalk between brand and generic drug names. Individuals who are inexperienced or who do not have medical terminology and clinical workflow knowledge may resort to Google or other self-help techniques to fill in gaps in what they know. This could lead to documentation errors which could contribute to lower quality care, harm to patients and practitioner liability. Some experts have suggested that the effort required to review and correct notes scribed by inexperienced or poorly trained individuals could actually slow the clinical workflow and increase the amount of time the provider will need to spend revising and finalizing progress notes. (Patrice A. Harris, MD, MA, Study of Minimum Competencies and Scope of Medical Scribe Utilization, Report of the Board of Trustees of the American Medical Association No. 20-A-17 (2017)).

How Should the Work Flow Be Structured?

Within the limits of the Ambulatory Care Policy and the principles set forth in this Guide, the Team Leaders should have flexibility to develop a model that works best for their practice. The following is a list of resources that describe models that have been effective at URMC and at other Academic Medical Centers:

What Team Members Can and Cannot Do

The role of team members in care delivery and care documentation must be structured carefully to ensure that the team leader who will be billing for the service performs the minimum elements of the service required under applicable billing and payment rules. The sections that follow describe the permissible role of team members in the components of evaluation and management services. For the convenience of the reader, the Compliance Office has also developed a Team Based Documentation Grids that sets for these requirements in a table that allows for easy comparison and reference.

History of Present Illness

A team member may obtain the History of Present Illness (HPI) from a patient or patient family member and present this information to a practitioner participating on the team. The team member may not independently document the HPI. The practitioner must independently document the HPI in the patient’s electronic medical record or have the team member scribe it.

Review of Systems and Past Medical, Family and Social History

A team member may independently document both the Review of Systems (ROS) and the Past Medical Family and Social History (PFSH) from a patient or patient family member. The billing practitioner must then review the information elicited by the team member and confirm it with the patient/family member. Alternatively, if a practitioner on the team develops the ROS and PFSH through discussions with the patient or a family member, the team member may scribe the information in the presence of the practitioner.

Physical Examination

Only the practitioner may perform the physical examination. The involvement of team members in the examination is strictly limited to scribing the work done by the practitioner in the presence of the practitioner.

Medical Decision Making

Only the practitioner may perform the medical decision making.

Ordering Services

Each hospital has written policies that identify the individuals who are permitted to enter orders. These policies must be adhered to when providing services in a team based model. For example, at Strong Memorial Hospital, Policy 8.01 permits unlicensed persons acting as scribes to enter “low risk orders” such as laboratory tests, electrocardiograms, medication refill orders, basic imaging orders, orders for physical or occupational therapy, and orders for activity, diet and measurement (e.g. pulse oximetry and CIWA). The orders must be signed by the supervising provider before becoming active. Scribes are expressly forbidden from entering medication orders that are new or involve dose or frequency changes. They may not enter orders for interventional procedures, nuclear medicine tests or imaging stress tests. If the proposed work flow involves the use of orders that are not addressed in hospital policy, the unlicensed team member may not enter the orders. Any questions should be referred to your Compliance Analyst/Educator.

Special Considerations for Teaching Physician Services

Physicians who adopt team based documentation must continue to comply with the Medicare and Medicaid teaching physician rules when working with medical residents and fellows. They must provide the requisite supervision. In the case of E&M visits they must document either that they performed the service or that they were present for the key and critical portions of the examination. As set forth in the Team Based Documentation Grids, a team based documenter may obtain, independently document or scribe the same elements of the examination for the teaching physician that a team based documenter is permitted to obtain, document or scribe if the service was performed by the teaching physician without the involvement of a resident. A team based documenter could also scribe services performed by the resident. But the involvement of the team based documenter does not eliminate the obligation of the teaching physician to document their presence or participation.

Special Considerations for Shared Visits

Under Medicare’s shared billing rules, when an E&M visit is shared between a physician and an APP from the same group practice and the physician provides any face to face portion of the E&M encounter with the patient, the service may be billed under the physician’s billing number. The physician must document his or her personal participation in the encounter. An attestation is not sufficient; the physician must add an addendum to the note that should include at least two of three categories: history, physical examination, or medical decision-making. Team based documentation does not supplant the shared billing rules. An APP is not an appropriate person to scribe the services performed by a physician. A physician cannot, under the guise of team based documentation, delegate the performance and documentation of an entire E&M encounter to an APP and bill the encounter as a physician service.

The physician must still see the patient and personally perform part of the E&M service and must document his or her participation in at least two of the three categories. However team based documenters may assist the physician and the APP in certain ways. They may:

  • Obtain the history of present illness and present it to the physician or APP;
  • Independently document the review of systems and the past family and social history;
  • Scribe any elements of the E&M performed by either the physician or APP in the presence of the billing provider.

A team documenter may also scribe the physician’s addendum which sets forth the physician’s personal participation in the encounter.

The Team Based Documentation Grids includes a grid that describes in detail the specific roles that apply and the attestations that should be used when team based documentation is used to support shared billing.

Signatures and Attestations

Medicare and other payers require documentation of services to be authenticated by the person responsible for the care using a timed, dated electronic signature. Authentication should consist of more than the electronic signature of the billing provider; it should be accompanied by an attestation sufficient to describe the involvement of the billing practitioner (the Team Leader) in the provision of care, and to confirm the accuracy and completeness of all of the documented services, whether obtained or scribe by a team member or documented by a practitioner involved in the care. The Compliance Office has developed a form attestation. The attestation is included in the Team Based Documentation Grids.

As a matter of URMC policy, team members are also required to attest to the services that they provide. The Compliance Office has also developed two form attestations for this purpose which are included in the Team Based Documentation Grids.