What is UCSF policy regarding the use of scribes for billing documentation?
UCSF does not allow the use of a “scribe” for the teaching physician. The documentation guidelines specifically require that the teaching physician “must personally document their participation in the service in the medical record”. The UCSF Code of Conduct specifies adherence with documentation guidelines as detailed in the UCSF Clinical Enterprise Compliance Manual. [top] When can time be used to determine E/M level? When counseling and co-ordination of care dominate (more than 50%) of the physician/patient time in the office or other outpatient setting or floor/unit time in the hospital, then time may be considered the key or controlling factor to qualify for a particular level of E/M services. The extent of counseling and coordination of care must be documented in the medical records. For coding purposes, the time the physician spends face-to-face with the patient is the time that is used to determine the level of service for outpatient E/M services. For coding purposes, the time t
