decisionhealth Newsletters, Coder Pink Sheets - 2008 Issue 5 (May)
Caution: When using scribes, only the doctor’s documentation counts
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Article Overview
This article discusses how documentation from scribes and ancillary staff is treated in physician office and evaluation and management settings. It is aimed at coders, compliance staff, and clinicians who need a general understanding of how documentation responsibilities, history-taking, and physician review practices are addressed by Medicare carriers and CPT guidance. The article also touches on the risks and operational concerns associated with scribing.
Why This Topic Matters
Documentation source and authorship can affect whether record elements are considered valid for coding and compliance purposes. The article helps readers understand the broader documentation and oversight issues that may influence evaluation and management reporting.
Article Sections
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Scribing and documentation basics
Introduces the role of scribes in clinical encounters and discusses general expectations for documentation attribution and review.
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HPI and new patients
Reviews broad documentation considerations for history-taking in new patient encounters and references guidance from coding and Medicare sources.
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When patients change their tune
Addresses variability in patient-reported histories and the implications for documenting information used in coding review.
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Is scribing an effective approach?
Explores operational and compliance concerns related to using scribes in practice settings.
What You Will Learn
- How scribe-assisted documentation is generally treated in clinical records
- Why history-taking documentation matters for evaluation and management encounters
- How carrier guidance can affect documentation practices
- What broad compliance concerns are associated with scribing
Who Should Read This
- Medical coders
- Compliance professionals
- Physicians
- Advanced practice providers
- Practice managers
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