Auditing the Use of a Scribe

December 1st, 2017 - Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT
Categories:   Documentation Guidelines   Electronic Medical Records (EMR/EHR)   Medical Records  
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A scribe is someone that can act as a walking transcriptionist on behalf of a medical provider. Oxford Dictionary defines a scribe as: "A person who copies out documents, especially one employed to do this before printing was invented."

Merriam-Webster defines a scribe as: "An official or public secretary or clerk."

The Joint Commission defines a scribe as:

A scribe may be a staff member that accompanies a provider into the room when seeing a patient and they document what they see, hear, and observe. A scribe should not add anything additional to the documentation and may not perform any of the work of the encounter, outside of the ROS and PFSH as permitted through 1995 and 1997 Documentation Guidelines.

Scribes may NOT:

The scribe is required to indicate within the documentation that they were used to create the documentation. Furthermore, the provider is also required to provide an attestation statement indicating that they have reviewed the documentation for accuracy and if supplemental information was required, it has been added. For this, CMS indicates the provider's signature of the documentation is not enough, and a separate attestation statement is required.

Examples of approved scribe statements and provider attestations are as follows:

Identification of scribe:

'______ scribing for Dr.______' or '______ is scribing for me today'

Notation from physician/NPP that he/she reviewed for accuracy:

'I agree with the above documentation' or 'I agree the documentation is accurate and complete'

EMR/Dictated Note:

Identification of scribe:

'Dictated by ______'

Notation from physician/NPP that he/she reviewed for accuracy:

'I agree with the above documentation' or 'I agree the documentation is accurate and complete'

In May 2017, CMS updated the Medicare Program Integrity Manual with regards to Signature Requirements for Scribes. It seems this was more of a clarification as the guidance is marked as a "Note." The manual now states specifically that "CMS does not require the scribe to sign/date the documentation." Again, this appears to be policy regarding the signature only and has no effect on the attestation statement.

However, there is one sentence in this note that creates yet another grey area.

"The treating physician/non-physician practitioner (NPP) signature on a note indicates that the physician/NPP affirms the note adequately documents to the care provided."

The seems to contradict the need for the physician attestation statement, however, all scribe rules still indicate the requirement for the attestation statement.

CGS Medicare has published Scribe Guidelines that supersede most MACs and due to the specific guidance, it provides- it is worth an honorable mention and review of those highlights. This document was published April 2012, and revised February 2017.

Your MAC may not be CGS, but if your organization is a hospital owned practice(s) who are JCAHO accredited then you will be required to follow these rules, and this is a significant difference then CMS guidance.

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.

Again, CGS is only one MAC, but this statement if used by other MACs could have a significant impact on audits as most EMRs hold who documented the information and not necessarily who reviewed it.

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