Written by Nicole Benson, Audit Manager, BA, CPC, CPMA, COSC
Were you aware that the regulations over medical student participation in documentation changed on March 5, 2018? Recently, there was a significant policy change by CMS in the documentation requirements provided by the medical students that you are mentoring in clinic. Prior to January 1, 2018, the CMS Guidelines for Teaching Physicians (MLN ICN #006347) stated that “if a student documents an E/M service, the teaching physician (or other qualified health care individual) must document a stand-alone note and re-document the HPI, PE and medical decision making portion of the note.” Medical students were restricted to the same documentation standards as ancillary staff, burdening providers with full encounter documentation while overseeing their students.
Now, teaching physicians and other qualified providers may “verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work” (MLN MM10412). Students may now document in all portions of the patient’s medical record.
This revision to the Medicare Claims Processing Manual still requires teaching physicians to personally perform or re-perform the physical examination and all medical decision making activities of the service being billed. But rather than re-documenting the medical student’s encounter note, the note may now be verified. GCS recommends a supporting attestation statement by the provider as well as corresponding signatures and credentials of all parties involved in the documentation, in other words both the student and teaching provider.
An example attestation statement may include but is not limited to the following:
I, Dr. Doe, was personally present with Jane Smith, MS through the entire patient encounter and personally performed the physical exam. The student documented all areas of the history and exam which I have verified (agree/disagree) before completing the assessment and plan portions of the note.