Railroad Medicare: Medical Review Top Denials Webinar: Questions and Answers

Published 10/09/2020

The following questions were received during our September 17, 2020, webinar.

Question 1: Is the provider that uses the assistance of voice recognition scribe, or transcription service responsible for reviewing and updating any discrepancies within the documentation prior to signing and billing the claims for each date of service? Does the use of voice recognition software fall under the guidelines for complying with Medicare signature requirements? Is the MLN booklet ICN 905364 from May 2018 the best resource for this?

Answer 1: The Complying with Medicare Signature Requirements MLN Fact Sheet (ICN 905364) is a great resource for this information. 

This resource answers your questions on Page 2 and defines a handwritten signature as a mark or sign by the ordering or prescribing physician or an NPP on a document that signifies knowledge, approval, acceptance or obligation.

If a provider uses a scribe, then they must sign the entry to authenticate it adequately. This documents the care you provided or ordered. It is unnecessary to document who transcribed the entry.

Overall, a provider’s signature attests that the entry is correct. Per this MLN fact sheet, this is true “regardless of who writes a medical record entry” and it is “unnecessary to document who transcribed the entry.” This applies to apply to both human scribe and voice activated transcription software.” The signature of the provider is for “signifying knowledge, approval, acceptance, or obligation” related to the medical record documentation.

Another resource is from the CMS Medicare Program Integrity Manual, Chapter 3 (PDF, 641 KB), Section (policies for Medicare signature requirements). Here you will find the following notation: 

Note: Scribes are not providers of items or services. When a scribe is used by a provider in documenting medical record entries (e.g., progress notes), CMS does not require the scribe to sign/date the documentation. The treating physician’s/nonphysician practitioner’s (NPP’s) signature on a note indicates that the physician/NPP affirms the note adequately documents the care provided. Reviewers are only required to look for the signature (and date) of the treating physician/nonphysician practitioner on the note. Reviewers shall not deny claims for items or services because a scribe has not signed/dated a note.

Question 2: If our payment was reduced (downcoded) for E/M services because the documentation was not legible to the reviewer, what should I include in an appeal request?

Answer 2: In order for the service to be accurately scored, documentation must be legible to the clinician. In this case, you could submit a typed version of your notes for the visit. It would assist the reviewer in determining the specific services performed that day.