The Role of Scribes in Clinical Documentation Integrity

By
Original story posted on: August 21, 2017
Upon seeing signature attestations of medical scribes on client documents, I became curious as to their duties and training. I was interested in exploring a way in which they may contribute to the goal of clinical documentation improvement (CDI) programs.

Since scribes can be employed in any healthcare environment or setting, their support of clear, complete and quality documentation can cover a broad spectrum of situations. They can act as a prompt for further specification, clarity, healthcare compliance and quality measures, evaluation and management, and other quality and compliance measures, including those in legislation such as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

Medical scribes are in an ideal position to improve documentation by their concurrent charting and interaction with physicians. Further research supported the positive benefits of scribes in efficiency and productivity, so I suggest that it is time to invite scribes to join the CDI team in order to enhance clinical documentation integrity.

There are multiple sources for reviewing a scribe’s education, training, duties, responsibilities, credentials and accreditation, and signature and authentication requirements, including: 

  • The Joint Commission (July 2012, Guidelines for the Use of Scribe)
  • The Centers for Medicare & Medicaid Services (CMS) (Transmittal 713, revised May 5, 2017)
  • American Health Information Management Association (AHIMA) (Journal of AHIMA, “Using Medical Scribes in a Physician Practice,” Nov. 2012, pp 64–69).

Other organizations, including the following, also address the topic:

  • Association of Clinical Documentation Improvement Specialists (ACDIS)
  • American College of Emergency Physicians (ACEP)
  • American Association of Professional Coders (AAPC).

I recommend that we include scribes in CDI and coding training and as a resource for ways in which to improve both communication between the physician and CDI team and documentation.

A July 2017 Journal of AHIMA article entitled “CDI Programs Expanding Outside the Hospital” notes that the American Medical Association recognizes the use of medical scribes on the CDI team. As the accuracy of coding and documentation increasingly becomes a fraud-and-abuse issue and a measure of both quality of patient care and physician performance, there is a continued need to innovate CDI programs and add new resources. Scribes may be one of the best resources to provide quality documentation at the initial time of the encounter. We should not overlook this opportunity.

I recommend, when employing scribes, either as a provider or as a healthcare management company that uses scribe documentation, to include the following in the Coding and CDI Compliance Program: signature requirements, physician authentication, scope of practice, credentialing, and job duties. There should be an expressed statement that a scribe may not act independently and acts only under the direction of a physician or licensed non-physician practitioner (NPP). Remember, third-party payers and Medicare Administrative Contractors (MACs) may have their own signature requirements. 

When scribes are used, a policy on physician authentication should be firmly and consistently adhered to for the protection of the validity of the documentation and its subsequent use for code assignment. Also, it should be clear that the scribe is to act as a prompt for better documentation and is not there to question the physician’s or NPP’s clinical judgment or to add or change documentation on their own.

Although their role in CDI may be restricted, it is nevertheless valuable. As part of the interdisciplinary CDI team, a scribe’s role should be seen as another opportunity for CDI success.

Let’s welcome medical scribes to the CDI team!
Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.

Brigid T. Caffrey, BA, BS, MS, CCS, CAC is a product specialist with Optum360. She has presented at AHIMA and Optum360 conferences on CDI and Clinical Validation. She is co-authored the first edition of “Guide to Clinical Validation, Documentation and Coding.”

Related Stories

  • ICD-10: Pitfalls of Noncompliant Queries
    Noncompliant queries can be overt or subtle.The underlying hallmark of clinical documentation integrity (CDI) programs is the query process utilized to clarify documentation from a diagnosis perspective. Much emphasis is placed upon ensuring the issuing of a compliant query by…
  • The Changing Face of the Social Determinants of Health: Implications for Hospitals
    Rapidly shifting societal demographics impact SDoH. 2018 saw the Social Determinants of Health (SDoH) rise to be among the most popular hot topics for the healthcare industry. In 2018 alone: $1.7 trillion in care was attributed to 5 percent of…
  • Appealing Clinical Validation Denials is a Team Effort
    Clinical validation denials continue to climb. When payers issue clinical validation denials, they challenge diagnoses documented in the chart by the providers caring for the patient. Sometimes, it’s not simply the validity of diagnoses in question, but whether coding rules…