General Question for the Week of November 19, 2018

Question:

Our providers use scribes to document entries in the medical records. Does Medicare require the scribes to sign the notes?

Answer:

Scribes are not providers of items or services. When providers use scribes to document medical record entries (e.g., progress notes), no signature or date is required. The treating physician’s or non-physician practitioner’s (NPP’s) signature on a note indicates that the note adequately documents the care provided. Reviewers will look for that signature (and date) on the note and will not deny claims for items or services because a scribe has not signed and dated a note. For more on this, go to a May 5, 2017 transmittal at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R713PI.pdf.