- Avoid Processing Delays by Following Proper Submission Guidelines
- Medicare Beneficiary Eligibility Checklist
- Acceptable Electronic Signatures Reminder
- Capable Recipients for the Advance Beneficiary Notice of Noncoverage
- Hospital-Issued Notices of Noncoverage
- Medicare Advance Written Notices of Noncoverage Booklet
- Primary Care Exception Guidelines
- Ordering DMEPOS Items
- Appropriate Use Criteria Program
- Assistant at Surgery Billing Documentation Reminder
- Avoid Return to Provider and Claim Rejections-Enhancing the Beneficiary Eligibility Verification Process
- Checking Eligibility and Knowing Your Point of Contact
- Cloned Documentation Could Result in Medicare Denials for Payment
- Documentation Reminder: Psychiatry and Psychology Services
- Documentation Required for Home Visits
- Electrical Stimulation Therapy: Important Coverage and Documentation Reminders
- Go Paperless Today - Protect Your Bottom Line
- Hospital Acquired Conditions and Present on Admission Resource for Physicians
- Inpatient Admission Prior to Medicare Entitlement Job Aid
- MDS Calendar
- Medicare Home Health Collaboration with Other Provider Types
- Part A Claims for High Cost Items and Certain Drugs Requiring Additional Information
- Manual Review of Claims for Replacement of Supplies and Accessories used with External Ventricular Assist Device
- Referring, Monitoring and Certifying Home Health Services
- Scribing Medical Record Documentation
- Skilled Nursing Facility Medicare Part A Benefit Quick Reference Fact Sheet
- Submit Medical Record Documentation Electronically
- Submitting Electronic Medical Records via CD-ROM
- Using the Medicare Part B PWK Fax-Mail-esMD Cover Sheet
Scribing Medical Record Documentation
National Government Services recognizes an increasing trend in providers’ use of scribes as assistants in medical record documentation. In these situations, a provider utilizes the services of staff to document work performed by the provider, in either an office or a facility setting.
In documenting any patient encounter, the scribe neither acts independently nor functions as a clinician, but simply records the provider’s dictated notes during the visit. The provider who receives the payment for the service is expected to deliver the service and is responsible for the medical record; the scribe may simply enter information on the provider’s behalf, all of which must be corroborated (i.e., approved) by the provider.
Some electronic medical record programs allow the provider to amend the scribe’s entry before the provider signs and enters the note into the record; this is permissible. When a scribe enters on a paper medical record and correction is needed, the provider must add and sign an addendum to the scribe’s note, rather than cross out or alter what the scribe has written.
During a patient encounter, the scribe may additionally perform standard medical assistant functions, as long as the scribe remains available to the provider and free to document the provider’s verbal observations in real time. The act of scribing is intended to take place as the provider dictates his/her notes regarding the patient’s history, exam and plan of care. The scribe is not permitted to record any independent notes, but only those specifically dictated by the provider.
Physicians using the services of a "scribe" must adhere to the following:
- The treating provider (physician or NPP) must sign and date the note to indicate that it is an accurate record of his/her words and actions during that visit.
- Documentation must support the medical necessity of the level of service billed and the level of medical decision making associated with the presenting problem. See Related Content for E/M guidelines.
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In the office setting, a staff member may independently record the PFSH and the ROS, and may act as the provider's scribe, by simply documenting the provider's words and activities during the visit. Of note, an NPP accomplishing the entire visit should report those services under his or her own PTAN, unless "incident to" guidelines have been met. Only when the "incident to" guidelines have been met, should the physician's name and NPI be used to bill Medicare for that service.
In a facility setting (hospital or skilled nursing home), when a NPP independently performs and documents an E/M service, the NPP is not functioning as a scribe, even if the documentation is later reviewed and/or co-signed by a physician. The service does not qualify as a split/shared visit, since the NPP performed the full service. “Incident to” concepts do not apply in the inpatient setting, and work performed exclusively by a NPP should be billed under the NPP's name and NPI.
Scribe usage may be appropriate and included in a Medicare provider's practice, when properly administered and documented. The Medicare provider must assume full responsibility for the performance, documentation, coding and billing of any scribed service.
Related Content
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60.2
- MLN Booklet® Evaluation and Management Services Guide
- Level I and Level II CPT Books: American Medical Association
- MLN General Information
Revised 11/6/2023