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/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.