CMS Broadens Scope of Medical Student Documentation

Great News for Teaching Physician Organizations. Time saver alert!

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Implemented on March 5, 2018, CMS relaxed the teaching physician guidelines to allow for broader usage of medical student documentation.  Previously, CMS restricted student documentation to solely recording the review of systems (ROS) and past medical, family, and social history (PFSH). The teaching physician would need to document or re-document any other aspects of the visit.  The update allows the teaching physician to utilize the student’s documentation of the entire visit. 

As with all changes, there are requirements that must still be met.

  • The teaching physician must verify, in the medical record, all the documentation and findings, including all the key components of evaluation and management (history, exam, and medical decision making) and must personally perform (or re-perform) the physical exam and medical decision making aspects of the visit; including documenting any changes to the student generated note. 
    • This is a significant time saver for physicians and minimizes held claims previously lacking necessary physician re-documentation.
  • HRG recommends that an appropriate attestation statement be included within the body of the note to eliminate future verification steps.
  • HRG also recommends educating your teaching physicians on the compliance aspects of this rule, ensuring documentation is an accurate and complete reflection of the work performed.

An example of a qualifying attestation statement would be: 

I personally reviewed, verified, and agree with the student documentation, as written, and personally performed the physical examination and medical decision making aspects of this patient visit.

In the event the teaching physician needs to make changes (including corrections, additions, or removal of portions of the student documentation), an example of a qualifying attestation statement would be: 

I personally reviewed, verified, and agree with the student documentation, made appropriate modifications, and personally performed the physical examination and medical decision making aspects of this patient visit. 

 

CMS Link: E/M Service Documentation Provided by Students

 

About the Author

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Teresa Tate-Weyer

DIVISION DIRECTOR OF HIM CODING FOR HEALTHCARE RESOURCE GROUP, INC. 

Teresa is a certified medical coder with over 20 years of experience spanning the full revenue cycle, including coding, billing, denial management, and provider education. Teresa has been with HRG for nine and a half years and currently oversees 17 project teams. Helping organizations, providers and coders alike, demystify the gray areas of E/M coding, has been a long-time passion. Teresa has had the opportunity to travel to different regions and forums, throughout the United States, providing insight into medical necessity and compliant coding.  She has enjoyed frequent speaking opportunities including organization leadership teams, tribal education forums, and individual and provider groups. Teresa previously served as both the Vice-President and President of the Spokane AAPC chapter.   

 


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