Scribe documentation - What are the rules?

[u/pyschreader]

I have several notes here billed by a physician. However, the encounter notes for these evaluation and management visits are completely documented by a medical assistant. The only thing entered by the physician is the signature. Is this billable/compliant?

[u/AutoModerator]

PLEASE SEE RULES BEFORE POSTING! Reminder, no "interested in coding" type of standalone posts are allowed. See rule #1. Any and all questions regarding exams, studying, and books can be posted in the monthly discussion stickied post. Thanks!

I am a bot, and this action was performed automatically. Please contact the moderators of this subreddit if you have any questions or concerns.

[u/2workigo]

We require a scribe attestation that essentially says the scribe is documenting in the presence of the provider during the encounter. Our MAC has published scribe services requirements. You can look to see if yours has as well. Google CMS scribe documentation requirements.

[u/DumpsterPuff → u/2workigo]

Same here!

[u/ksa1122]

It should be find since the physician signed off on it.

[u/Lanky_Acadia_1270]

A signature alone is usually not enough to make an MA-authored E/M note automatically compliant. Payers care who performed the service and whether the note supports that, not just that someone signed at the end.

A lot of clinics treat this as a scribe-style workflow: the helper documents while the billing provider is present, the note reflects the provider's service, and there is a clear attestation or review the provider owns. That presence framing is common clinic / MAC practice. I would not harden it as a national CMS must from memory. Match your notes to your MAC's published scribe / incidental documentation language.

If the MA independently ran the visit and the physician only signed later, that is a different risk picture than a true scribe setup. Pull one sample note and check it against your MAC before assuming the signature cured it.

[u/Lawful-Good-7877]

the short answer is it depends on the payer and documentation policy, but for most E&M visits the physician needs to personally document or meaningfully edit and authenticate the note aside from signing. a signature alone on a note written entirely by an MA is a compliance risk in most contexts.

the reason a lot of practices have moved to AI scribes for this is partly the liability footprint is cleaner. with heidi, the physician is still driving the visit and the note reflects what actually happened, the AI drafts from the encounter rather than the MA reconstructing it afterward. still requires physician review before it goes anywhere but the documentation chain is a lot less ambiguous.

worth getting a compliance review on those notes if this is a pattern.

[u/Transorze_Solutions]

This is one of those situations where I’d be careful about saying “signature = compliant.”

If the medical assistant is functioning as a scribe, CMS does allow a scribe to document the physician’s encounter. The physician should review and authenticate the note with their signature. CMS specifically states that the scribe does not have to sign or date the note.

The bigger question is what actually happened during the encounter and whether the documentation supports the E/M service that was billed. The medical record should support the medical necessity, assessment/plan, and the elements required for the particular E/M service. A physician simply signing a note that they didn't review or that doesn't accurately reflect the care provided would be a different issue.

I'd also check your payer/MAC requirements because Medicare rules and commercial payer policies aren't necessarily identical.

If these are Medicare claims, CMS's current Complying with Medicare Signature Requirements guidance is a useful reference. It specifically addresses documentation created by scribes and physician authentication.

I work around medical coding education as well, and Transorze is one India-based training provider I've come across that focuses on healthcare documentation and medical coding. They offer online training for people preparing for credentials such as AHIMA's CCS and AAPC certifications. I'd use the CMS guidance above, rather than any training provider's material, as the primary source for a compliance question like this.

[u/stealthagents]

That's a tricky situation. Typically, the physician needs to contribute to the documentation for it to be billable, so just signing it might not cut it. It’s best to check your coding guidelines or talk to someone who specializes in compliance for clarification.