April 9, 2012
Non-Physicians Acting as Scribes for Physicians
Recently CGS has noted some physicians having another individual write notes in the medical record for them, and then the physician merely follows behind and signs the note. This may be inappropriate and education is especially important with the increased implementation of Electronic Medical records (EMRs).
If a nurse or Non-Physician Practitioner (NPP) acts as a scribe for the physician, the individual writing the note or entry in the record should note "written by (Jane Doe), acting as scribe for Dr. (Smith)." Then, Dr. (Smith) should co-sign, and indicate the note accurately reflects work and decisions made by the physician. The scribe is functioning as a "living recorder," documenting in real time the actions and words of the physician as they are done. If this is done in any other way, it is inappropriate. The real time transcription must be clearly documented as noted, by both the scribe and the physician. Failure to comply with these instructions may result in denial of claims.
Increasingly, CGS is seeing components of evaluation and management services completed or updated by nursing or other medical staff in the EMR. For example: In the Past Medical or Family/Social History sections, there is an electronic note stating "updated by Nancy Jones, Medical Technician" or an electronic statement of "medication list updated by Mary Smith RN." If the physician does not review and address these components as well; and the only documentation relating to these components is the entry from the nurse or a medical technician, then these components may not be used in determining the level of E&M service provided as they do not reflect the work f the physician.
It is also inappropriate for an employee of the physician to round at one time, make entries in the record, and then for the physician to round several hours later and note "agree with above," unless the employee is a licensed, certified NPP billing Medicare for services under the NPP name and number.
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. This requirement is no different from any other encounter documentation requirement. 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 the affirmation above, that the note accurately reflects work done by the physician.