Radiology Question for the Week of July 10, 2017

Question:

Our physicians use scribes for documentation. Does Medicare require that the scribe sign the medical record?

Answer:

Per the Medicare Program Integrity Manual (section 3.3.2.4), scribes are not providers of items or services. When a provider uses a scribe to document medical record entries (e.g., progress notes), a scribe is not required to sign and date the documentation. The treating physician’s/non-physician practitioner’s (NPP’s) signature on a note indicates that he or she affirms that the note adequately documents the care provided. Reviewers are only required to look for the signature (and date) of the treating physician or NPP on the note, and they will not deny claims for items or services because a scribe has not signed and dated a note.