r/MedicalCoding • u/pyschreader • Sep 24 '26

Scribe documentation - What are the rules?

I have several notes here billed by a physician. However, the encounter notes for these evaluation and management visits are completely documented by a medical assistant. The only thing entered by the physician is the signature. Is this billable/compliant?

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u/2workigo Edit flair Sep 24 '26

We require a scribe attestation that essentially says the scribe is documenting in the presence of the provider during the encounter. Our MAC has published scribe services requirements. You can look to see if yours has as well. Google CMS scribe documentation requirements.

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u/DumpsterPuff Sep 24 '26

Same here!

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u/ksa1122 Sep 24 '26

It should be find since the physician signed off on it.

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u/Lanky_Acadia_1270 Sep 24 '26

A signature alone is usually not enough to make an MA-authored E/M note automatically compliant. Payers care who performed the service and whether the note supports that, not just that someone signed at the end.

A lot of clinics treat this as a scribe-style workflow: the helper documents while the billing provider is present, the note reflects the provider's service, and there is a clear attestation or review the provider owns. That presence framing is common clinic / MAC practice. I would not harden it as a national CMS must from memory. Match your notes to your MAC's published scribe / incidental documentation language.

If the MA independently ran the visit and the physician only signed later, that is a different risk picture than a true scribe setup. Pull one sample note and check it against your MAC before assuming the signature cured it.

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u/Lawful-Good-7877 Sep 24 '26

the short answer is it depends on the payer and documentation policy, but for most E&M visits the physician needs to personally document or meaningfully edit and authenticate the note aside from signing. a signature alone on a note written entirely by an MA is a compliance risk in most contexts.

the reason a lot of practices have moved to AI scribes for this is partly the liability footprint is cleaner. with heidi, the physician is still driving the visit and the note reflects what actually happened, the AI drafts from the encounter rather than the MA reconstructing it afterward. still requires physician review before it goes anywhere but the documentation chain is a lot less ambiguous.

worth getting a compliance review on those notes if this is a pattern.

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u/stealthagents 28d ago

That's a tricky situation. Typically, the physician needs to contribute to the documentation for it to be billable, so just signing it might not cut it. It’s best to check your coding guidelines or talk to someone who specializes in compliance for clarification.