Part B Documentation: Heed This MAC Tip on Documentation by Ancillary Staff

Why This Topic Matters

Documentation responsibilities can affect whether an E/M service is supported in the medical record and whether billing under a physician’s identifier is appropriate. Understanding these distinctions helps practices reduce claim risk and align recordkeeping with Medicare contractor guidance.

Article Sections

1. Ancillary staff documentation and physician responsibility

   This section summarizes the Medicare guidance on the parts of the medical record that may be documented by ancillary staff versus the parts expected from the treating clinician. It also addresses how preliminary information should be treated in the record.

2. What about scribes?

   This section explains the general concept of scribes and how that arrangement differs from other types of documentation activity in a patient encounter. It also notes related billing and record-creation considerations described by the contractor guidance.