This is my carriers policy.....
Non-Physicians Acting as Scribes for Physicians
Recently we have noted some physicians having individuals writing notes in the medical record for them, and then merely signing the note. This may be inappropriate.
If a nurse or mid-level provider (PA, NP, CNS) acts as a scribe for the physician, the individual 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." Then, Dr. yyyy should co-sign, indicating that the note accurately reflects work and decisions made by him/her. Note: The scribe is functioning as a âliving recorder,â recording 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. This should be clearly documented as noted, by both the scribe and the physician. Failure to comply with these instructions may result in denial of claims.
It is inappropriate for an employee of the physician to round at one time and 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 provider (PA, NP, CNS) billing Medicare for services under his/her own 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.
It is acceptable for a physician to use a scribe, but current documentation guidelines must be followed. 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.
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