Knowledge Base Article

Q:

Several of our physicians sometimes have scribes do their documentation for them.  Do both the scribe and the physician have to sign this documentation?

A:

No; only the physician’s signature is required.  CMS recently released Transmittal 2017 updating the Medicare Program Integrity Manual to provide instructions to providers regarding signature requirements when scribe services are used by a physician/non-physician practitioner (NPP).

According to the Transmittal, “Scribes are not providers of items or services. When a scribe is used by a provider in documenting medical record entries (e.g. progress notes), CMS does not require the scribe to sign/date the documentation. The treating physician’s/non-physician practitioner’s (NPP’s) signature on a note indicates that the physician/NPP affirms the note adequately documents the care provided. Reviewers are only required to look for the signature (and date) of the treating physician/non-physician practitioner on the note. Reviewers shall not deny claims for items or services because a scribe has not signed/dated a note.”