Medical Scribe Confessions Medical Scribe Confessions

Medical Scribe Confessions

Michael Warner, DO, CPC, CPCO, CPMA, AAPC Fellow

This auditing and compliance “Tip of the Week” was originally published by the National Alliance for Medical Auditing Specialists (NAMAS), a division of DoctorsManagement.

It’s time for auditors and compliance officers to expect health records to contain accurate information.  As a medical school professor, I routinely interact with student doctors and Master of Science postgraduate students. Many of these individuals have functioned as scribes and their stories tug at the very core of medical compliance: they reveal that a large amount of information documented in healthcare records is fabricated.

Former scribes speak with trepidation of being told by providers to enter information into records that did not match the patient’s story. Frequently, the patient’s story was cut off and replaced with an auto-populated generic story. Often, templates were applied to add volume to records in order to satisfy billing scoresheets and reduce risks of failing an audit.

A September 18, 2019 article in The Journal of the American Medical Association (JAMA) observed resident physicians in the emergency department and compared their clinical experience to what was documented in the healthcare records. The Review of Systems (ROS), for example, was accurate only 40.1% of the time. If scribes were involved, accuracy dropped to 36.7%. [1]

CMS has not blamed medical providers but instead acknowledged a systems problem with how we gather patient information. With sweeping policy changes, CMS empowered medical students to document all components of Evaluation and Management (E/M) services in 2018, and empowered patients and ancillary staff members to document the History component of E/M notes in the outpatient setting in 2019. For 2021, the CMS Physician Fee Schedule (PFS) final rule in 2019 (affirmed again in the recent PFS proposed rule for 2020) will eliminate provider requirements to document the History or Examination for office visits. These actions are designed to reduce provider clerical burden.

I urge you to conduct an audit of your own healthcare record. If you find inaccuracies or an incomplete picture of your story, then consider taking advantage of the changes in CMS’ PFS final rule for 2019 to personally author your own History in preparation for your next medical encounter. If you are able to improve the accuracy of your healthcare record, then you will be able to advocate for accuracy of all such records.

As auditors and compliance officers, painting a clear picture of the patient in health records is a worthy goal. It makes sense that an accurate History will lead to a correct diagnosis and effective treatment plan. Let’s make sure these scribe stories are tales of the past.


[1] Berdahl, CT, Moran, GJ et al, Concordance Between Electronic Clinical Documentation and Physicians’ Observed Behavior, JAMA Netw Open, September 18, 2019

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2751388

 

This Week’s Audit Tip Written By:

Michael Warner, DO, CPC, CPCO, CPMA, AAPC Fellow

Dr. Warner is an associate professor at Touro University California, an AAPC National Advisory Board Member, represents the AOA as an alternate advisor on AMA RUC and is president of non-profit Patient Advocacy Initiatives.

What to do next…

  1. Contact us to discuss your audit needs by calling (800) 635-4040 or email info@drsmgmt.com.
  2. Read more: What can you expect from a coding and compliance review?
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