E/M Coding Alert - 2012 Issue 12
Know Which Notes Can Be Counted When Scribes Do the Documenting
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Article Overview
This article addresses how scribes may be used in clinical documentation workflows and what Medicare-related documentation expectations apply. It is aimed at physicians, practice managers, coders, and compliance staff who need to understand how scribe entries should be identified, verified, and incorporated into the medical record. The discussion covers general scribe handling, physician accountability, EMR access and attribution, ancillary staff documentation, and considerations when a licensed practitioner or non-physician practitioner is involved in the documentation process.
Why This Topic Matters
Scribe practices can affect record integrity, compliance, and claim defensibility. Understanding the documentation and attestation expectations helps practices avoid problems with payer audits and improper billing.
Article Sections
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Take heed of these rules when considering what the scribe can document
Introduces the role of scribes in clinical documentation and explains why payer-specific rules matter when practices use them in electronic records.
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Know What Medicare Says About Scribes
Summarizes Medicare-related expectations for scribe documentation, physician accountability, and record verification in covered encounters.
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Another Licensed Practitioner Acting As A Scribe? Beware
Addresses situations where another licensed practitioner or non-physician practitioner is involved in documenting on behalf of a physician and discusses how that differs from independent work.
What You Will Learn
- How scribes fit into physician documentation workflows
- What broad documentation and attestation concepts are emphasized for Medicare compliance
- How record attribution and physician verification are handled in scribe-based notes
- Why documentation by other practitioners may not qualify as scribe activity
- What general factors practices should consider before implementing a scribe program
Who Should Read This
- Physicians
- Medical practice managers
- Medical coders
- Compliance staff
- Billing staff
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