CODING & REIMBURSEMENT

Adding a scribe to your practice?

By Suzanne Corcoran

Increasingly a part of medical practices, a scribe is a technician or medical assistant who transcribes into the medical record what a physician dictates during an examination. Here’s what you need to know about them when it comes to coding.

Q Why would an ophthalmologist use a scribe?

A A scribe allows the physician to focus on the patient during the examination without compromising documentation in the medical records. For paper charts, a scribe may improve legibility. For electronic records, a scribe may improve the quality and quantity of the notes.

Q What is Medicare’s policy regarding scribes?

A Many Medicare Administrative Contractors (MACs) have policies on scribes. Novitas, the MAC for several states, says: “While the physician … must perform the … service, the scribe may document what is dictated and performed in the medical record. Documentation of scribed services must clearly indicate:

• who performed the service;

• who recorded the service;

• qualifications of each person (i.e., professional degree, medical title);

• signed and dated by both the physician … and scribe.”

Palmetto GBA, another MAC, suggests the following in its sample guidance as acceptable: “[Scribe name] scribing for Dr. [provider name].” Other MACs accept a notation by the scribe, such as “acting as scribe for Dr. X” in the chart.

Q Does EMR pose any special considerations for scribes?

A EMR tracks who logs in to make entries in the medical record, but doesn’t make clear if that person is a scribe, technician, or physician. Best practices include:

• Require physicians to review, edit and correct the scribe’s notations and attest to completeness and accuracy.

• Require that physicians log in to sign charts and not allow scribes to sign charts for physicians.

• Keep log-in passwords confidential — don’t share them between physicians and staff.

Scribing is different from taking VA or IOP. The same person should not perform these functions concurrently. If the person functions as both a scribe and tech, we suggest two different log-ins to facilitate the distinction for reviewers.

Q How does the physician attest to the accuracy of the scribe’s note?

A A physician might write: “I agree with the above documentation” or “I agree the above information is accurate and complete” to show she or he has reviewed the notes in the medical record as intended. The absence of an attestation may cast doubt on the veracity of the record. EMR should have a mechanism for the physician to indicate that the physician has reviewed and verified the scribe’s entries.

Q Are there restrictions on what a scribe can record?

A Yes. Organizations such as healthcare systems, teaching facilities and hospitals generally have different requirements for scribes. A scribe cannot document services such as extended ophthalmoscopy. Only the physician can make accurate retinal drawings.

Q Are there other legal considerations or restrictions?

A In some states physician assistants may not be eligible to use scribes. Regulatory requirements and a healthcare setting’s policies, and the level of risk an employer is willing to accept, ultimately control a scribe’s responsibilities.