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April 9, 2012 - Updated 02/23/2017

Revised per TDL 731, CR10076, Effective June 6, 2017

Non-Physicians Acting as Scribes for Physicians

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 by both the scribe and the physician. Failure to comply with these instructions may result in denial of claims.

  • Scribes are not providers of items or services. When a scribe is used by a provider in documenting medical record entries (e.g. progress notes), 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.
  • Documentation must identify who performed the service
  • The physician/practitioner MUST sign and date all documentation timely.

This revision is ONLY regarding the scribe signature requirements, it does not indicate that you do not need to note when a scribe is used.

Per the Joint Commission, which states is part:

The Joint Commission does not endorse nor prohibit the use of scribes. However, if your organization chooses to allow the use of scribes the surveyors will expect to see:

Compliance with all of the Human Resources, Information Management, Leadership (contracted services standard), Rights and Responsibilities of the Individual standards and Record of Care and Provision of Care standards including but not limited to:

  • A job description that recognizes the unlicensed status and clearly defines the qualifications and extent of the responsibilities (HR.01.02.01, HR.01.02.05).
  • Orientation and training specific to the organization and role (HR.01.04.01, HR.01.05.03).
  • Competency assessment and performance evaluations (HR.01.06.01, HR.01.07.01).
  • If the scribe is employed by the physician all non-employee HR standards also apply (HR.01.02.05 EP 7, HR.01.07.01 EP 5).
  • If the scribe is provided through a contract then the contract standard also applies (LD.04.03.09).
  • Scribes must meet all information management, HIPAA, HITECH, confidentiality and patient rights standards as do other hospital personnel (IM.02.01.01,IM.02.01.03, IM.02.02.01, RI.01.01.01).
  • Signing (including name and title), dating of all entries into the medical record-electronic or manual (RC.01.01.01and RC.01.02.01). For those organizations that use Joint Commission accreditation for deemed status purposes, the timing of entries is also required. The role and signature of the scribe must be clearly identifiable and distinguishable from that of the physician or licensed independent practitioner or other staff. Example: "Scribed for Dr. X by name of the scribe and title" with the date and time of the entry.
  • The physician or practitioner must then authenticate the entry by signing, dating and timing (for deemed status purposes) it. The scribe cannot enter the date and time for the physician or practitioner. (RC.01.01.01 and RC.01.02.01).

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 of the physician.

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.

Reminder: Documentation must support the medical necessity of the level of service billed. Please follow 1995 or 1997 Evaluation and Management (E/M) Documentation Guidelines referenced below.

References:

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