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Part B - News Article Detail - Documentation Requirements when Scribes are Utilized

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Connex Online Inquiry Customer Service (IVR and Telephone) Fee Schedules Forms Mailing Addresses Medical Policy Center (LCDs) Medicare Monthly Review News Articles

Documentation Requirements When Scribes are Utilized Physicians may occasionally utilize the services of scribes to assist with documentation during a clinical encounter between the physician and patient. The scribe is present during the encounter and records in real time the actions and words of the physician as they occur. Scribes may not interject their own observations or impressions into the medical record. Physicians may rely on the review of systems (ROS) and past, family, social history (PFSH) obtained and recorded by ancillary personnel. The physician is ultimately responsible for all documentation and must verify that the scribe’s note accurately reflect the service provided.

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The Scribe’s Note Should also Include Expand All | Collapse All

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Publications E-mail Updates Manuals Medicare Monthly Review

The The The The

name of the scribe and a legible signature name of the physician providing the service date the service was provided name of the patient for whom the service was provided

The Physician’s Note Should Indicate

News Articles

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Claims Administrative Simplification Compliance Act Coordination of Benefits

Affirmation of that physician’s presence during the time encounter was recorded Verification that he/she reviewed the information Verification of the accuracy of the information Any additional information needed

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Signature requirements detailed in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.1, (1 MB) as well as the specific documentation requirements for any service provided must be followed.

HCPCS Codes

Posted 12/17/2010

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Note: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material which is copyrighted by the American Medical Association (AMA). You are forbidden to download the files unless you read, agree to and abide by the provisions of the copyright statement. Read the copyright statement now (you will be linked back to here). CPT codes, descriptions, and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All rights reserved. Applicable FARS/DFARS apply.

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Last Modified: 12/17/10

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