Ophthalmology and Optometry Coding Alert

Question: We just started having one of our medical assistants act as a scribe for a physician who had carpal tunnel syndrome and is recovering from surgery. Does Medicare require the medical assistant to sign the medical record when she is documenting for the provider?

Delaware Subscriber

Answer: No, CMS does not expressly require scribes to sign or date documentation — and that’s because “scribes are not considered providers of items or services,” notes CR 10076 of the Medicare Program Integrity Manual.

Medicare claims reviewers are only required to look for the treating physician’s or non-physician practitioner’s (NPP’s) signature in the documentation or record. The clinician’s signature along with the date “affirms the note adequately documents the care provided,” Medicare guidance maintains.

Additionally, CMS insists that reviewers will “not deny claims for items or services because a scribe has not signed/dated a note,” according to the guidance.

But: “It is recommended to include the identity of the scribe within the medical record documentation as the recorder of the service performed,” advises Part B Medicare Administrative Contractors (MAC) Novitas Solutions in its scribe services tips.

Novitas also offers examples on the best way to address scribes in the documentation. For example, you might want to add a statement to notes listing the scribe’s name and that they are scribing for the physician or NPP.