By Valerie Weiss, MD
The role of a Medical Scribe
The medical scribe’s primary role is the generation and maintenance of the patient’s medical record, which is created under the supervision of the physician. The medical scribe shadows the physician and documents the patient’s story through the physician’s interaction with the patient. The scribe will also document any procedures performed and the results of any laboratory studies. Scribes document the roadmap of the patient while under the direct care of the physician. A well-written medical record will result in smoother claims processing and provides a medico-legal resource as to the care provided. Because the medical scribe’s role is clinically-focused on observing and documenting the patient’s encounter, many scribes use this invaluable experience as a stepping-stone to further their own education in the health arena.
The role of a Medical Transcriptionist
In contrast, a medical transcriptionist, while also in the healthcare field, does not see the patient alongside the physician. Typically, the medical transcriptionist works in a quiet office setting removed from the workflow of seeing patients. The medical transcriptionist’s job is to listen to a physician’s voice dictation and convert that into a written report. A growing trend in medicine is for a physician to utilize voice recognition technology while dictating. The software will convert the physician’s spoken word into a written record. Often, some of the dictation is lost in translation or interpreted incorrectly by the software. A medical transcriptionist’s role, in this case, is to review and edit these medical documents.
The role of a Medical Biller
Even though medical billing and coding are often lumped together, they are actually two distinct jobs. Essentially, a medical biller is a healthcare worker who is tasked with making sure everyone is billed correctly. A medical biller may talk to patients as well as health insurance companies to make sure all invoices are paid correctly and in a timely manner. A medical biller needs to understand coding language and how to read medical invoices.
The role of a Medical Coder
In contrast to a medical biller, a medical coder, does not have communication with the patient or insurance company. The medical coder spends time assessing the medical chart to make sure it is coded with the correct medical codes. Coders must be accurate. Medical coders employ the International Classification of Diseases or ICD. The World Health Organization periodically upgrades the ICD. The current model being used is ICD-10.