Do you know well when to ask for a scribe? Even though CMS does not offer any explicit official guidance on the use of scribes, there is some information disseminated by the CMS officials in response to user queries. Some of the carriers such as Novitas, WPS, and Palmetto also talk of points to bear in mind in this respect.
First and foremost, it is the physician who is accountable for the documentation in the records. He is expected to sign, confirming the records made by the scribe, upon dictation by the physician.
A scribe must enter information verbatim- as spoken by the provider. He must not add independently-any more lingo to what the provider said. Remember the Medicare does not pay for the services of a scribe, Further the documentation must clearly state the title, name, and signature of the scribe. Plus, the physician must ensure that all the services performed by the physician are being adequately reflected in the scribe’s documentation.
Be careful if your NPP is filling in as scribe: Although there are no restrictions as to who is eligible to fill in as a scribe, there is a growing payer’s concern regarding NPPs acting as scribes because of they also can independently evaluate the patient apart from the physician. At times it becomes quite confusing to distinguish the documentation performed by the same person as an NPP on one occasion, and as a scribe on other occasions. To make it clear, the person writing the entry in the record) should mention explicitly, that who was the scribe, and who was the physician. Then, the physician must authenticate the documentation, affirming that the note precisely matches the work performed by him on the patient.
How E/M service documentation is different than being a scribe: Suppose, a Non-Physician Practitioner documents for E/M services that he performed independently. Later on, as the physician comes for rounds, he review the findings and signs the records. This is more of an example of a shared service, rather than a scribe work. The provider may bill for it with his National Provider Number as a shared service.
In short, the physician will need to be very careful when it comes to taking the help of a scribe. First of all, even though this option may seem convenient and the provider can save time on documentation to examine or work on a greater number of patients, at the same time- there is always room for human error, miscommunication or missing a few words- which may land the physician into documentation errors and problems thereof. All said and done, it is the responsibility of the physician to assure the accuracy of the documentation, and make sure no confusion arises with the NPPs scribing for the physicians.