If the physician is having a PA (or other non-physician practitioner) write in the medical record for them, with the physician merely writing the note, they need to understand the potential compliance issues.
One of Medicare's contractors, CIGNA recently published an article on their website on this topic and indicated that:
If a mid-level provider, i.e., PA acts as a scribe for the physician, the PA writing the note (or history or discharge summary, or any entry in the record) should note "written by xxxx, acting as scribe for Dr. yyy."
The physician should co-sign, indicating that the note accurately reflects work and decisions made by him/her (physician).
In doing so, CIGNA made clear that the scribe is functioning as a real time recorder of the physicians words and actions and cannot be exercising any independent clinical judgment while scribing.
CIGNA also made clear that Medicare only pays for medically necessary services and expects the physician receiving payment to be the one delivering the services and creating the record. Specifically, there is no billing for scribe services.
In summary, "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" and that "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."
Hope this helps!
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