A scribe can be a non-physician practitioner (NPP), nurse or other appropriate personnel designated by the physician/NPP to document or dictate on their behalf. A scribe does not have to be an employee of the physician/NPP.

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), the Centers for Medicare & Medicaid Services (CMS) does not require the scribe to sign/date the documentation. The treating physician’s/NPP’s signature on a note indicates that the physician/NPP affirms the note adequately documents the care provided.

The Medicare Administrative Contractor (MAC) is only required to look for the signature (and date) of the treating physician/NPP on the note. Services shall not be denied for items or services because a scribe has not signed/dated a note.

Reference: CMS Change Request (CR) 10076/Transmittal 713 (PDF, 79 KB)