Editor’s Note: Cutting through the red tape to make certain that you get paid for every dollar you earn has become more difficult than ever, particularly in our current climate of health care reform and ICD-10 transition. The ACEP Coding and Nomenclature Committee has partnered with ACEP Now to provide you with practical, impactful tips to help you navigate through this coding and reimbursement maze.
Question: Do I have to document anything if I’m using a scribe?
Answer: All information obtained from a patient and recorded by a scribe must be done in the presence of a physician or advance practice provider (APP). Scribes work side by side with clinicians, documenting the service provided in real time or immediately afterward. Two separate attestations are required when using a scribe. The first is by the scribe, indicating that they are scribing for a particular clinician. The second, by the clinician, is more involved and should indicate that the scribe’s documentation accurately reflects the service(s) provided by the clinician. As always, it is important for the clinician to review the records for completeness and accuracy. Lastly, clinicians need to either recite to the scribe or document themselves the medical decision making and emergency department course. Much more information about scribe usage (including who can act as a scribe, Centers for Medicare & Medicaid Services and Joint Commission rules about scribes, and sample attestations) can be found here.
Brought to you by the ACEP Coding and Nomenclature Committee.
Dr. Lempert is chief medical officer, coding policy, at TeamHealth, based in Knoxville, Tennessee.