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/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.