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Scribes
- When a physician or NPP performs a service that is documented by a scribe, what are the documentation requirements?
Answer: As per CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4: “CMS does not require the scribe to sign/date the documentation. The treating physician’s/non-physician practitioner’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/non-physician practitioner on the note. Reviewers shall not deny claims for items or services because a scribe has not signed/dated a note.”
- Once the scribe enters his/her attestation can the provider change what the scribe wrote or should they just state the changes below the scribe attestation and above their own attestation?
Answer: Some EMR products will allow the provider to amend the scribe’s entry before the provider signs and enters the note into the record, and this is permissible. When a scribe enters on a paper medical record, the provider must add and sign an addendum to the scribe’s note, when corrections are needed, rather than cross out or alter what the scribe has written.
- Can a scribe assist the provider in the exam room by holding the patients head for example, or handing them instruments?
Answer: The scribe may perform standard medical assistant functions, as long as the scribe remains available to the provider during his/her time with the patient and free to document the provider’s verbal observations in real time during his/her time with the patient. The act of scribing is intended to take place as the physician dictates his/her notes regarding the patient’s history, exam and plan of care. As the physician moves through the encounter, and is ready to dictate those notes and comments, the scribe needs to be available, since the scribe is not permitted to record his or her own summary or notes regarding the patient encounter
- When a physician utilizes a scribe, what documentation is needed to affirm the physician's presence during the time the encounter was recorded?
Answer: The physician’s note, as documented by the scribe, must clearly indicate the physician’s face-to-face presence with the patient throughout the service. The scribed note must be documented during the visit, and not at a point thereafter.
Reviewed 10/8/2024