Scribed services are those in which the physician utilizes the services of ancillary personnel to document/record the work performed by that physician, in either an office and other outpatient or a facility setting. The scribe does not act independently, but simply documents the physician’s dictation and/or activities during the visit in the patients chart or Electronic Health Record (EHR).
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 of a scribed service must clearly indicate:
Who performed the service
Signed and dated by the treating physician or non-physician practitioner (NPP) affirming the note adequately documents the care provided
I agree with the above documentation' or 'I agree the documentation is accurate and complete' *
If an NPP is utilized and acting as a scribe for the physician, the medical record should clearly indicate the NPP is acting as a scribe. This applies to all scribed encounters, whether scribing was performed by licensed clinical staff or other ancillary staff.
Examples*
Billing provider’s note: ‘_______________, acted as scribe for this encounter on _________”,
Billing provider’s note: “_____________(scribes name) scribing for ___________(physician/non physician provider name)
It is recommended to include the identity of the scribe within the medical record documentation as the recorder of the service performed. It is expected that the use of a scribe to be clinically appropriate for each situation and in accordance with applicable state and federal laws governing the relevant professional practice, hospital bylaws and any other relevant regulations.
CR 10076: Scribe Services Signature Requirements
*These are examples of acceptable scribe documentation and do not serve as an endorsement or approval of such statements nor serves to demonstrate that any claim billed for services independent or in association with such statements will be paid under the Medicare program.
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