CMS Documentation FAQ

Preceptors may use student documentation for billing purposes if your clinic or hospital allows it. If you have not seen the guidelines for student documentation, (see handout).

Medical Student Documentation for Evaluation and Management Services

CMS Medical Student Documentation (Printable PDF)

CMS released a new rule allowing teaching physicians to use medical student documentation of evaluation and management services as a documentation burden reduction benefit only. The teaching physician must still perform the service as CMS does not pay for work performed by students. The new rule applies to teaching physicians (TP) – although residents can provide a limited supervisory role.

There are three basic scenarios:

Scenario 1: The Teaching Physician is present with the medical student for the E/M service

The TP is present while the medical student performs the history of present illness, the physical exam and medical decision making. The TP must re-perform the exam and medical decision making and verify the history of present illness. The teaching physician can then verify* and attest to the medical student’s documentation.

*Verify – make sure or demonstrate the documentation is true and accurate. This includes editing as needed.

Scenario 2: The medical student sees the patient first without the TP or resident present

If the medical student sees the patient first alone, the medical student must be present throughout as the teaching physician later confirms the history with the patient. The student must also be present as the TP performs their physical exam and articulates their medical decision making. The TP can then verify and attest to the medical student’s documentation.

Scenario 3: The resident is present with the medical student for the E/M service

If a resident and a medical student see the patient together without the teaching physician, and the medical student writes the note, the teaching physician must again repeat or confirm the entire patient history, perform the physical exam and express their medical decision making (with or without the medical student). Only then can the TP use the medical student’s note, again after verifying and attesting to it. The resident will attest to their presence with the medical student.

Additional FAQ’s clarifying the CMS update are included below.

Background: The Centers for Medicare & Medicaid Services (CMS) revised the Medicare Claims Processing Manual (MCPM), Chapter 12, Section 100.1.1, to update policy on Evaluation and Management (E/M) documentation to allow the teaching physician (TP) to verify in the medical record any medical student documentation of components of E/M services, rather than re-documenting the work. Medical students may document services in the medical record. However, the teaching physician must verify in the medical record all medical student documentation of findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify medical student documentation of them in the medical record, rather than re-documenting this work.

Q1. Does this mean I can bill for work performed by a medical student?

A1. No, this change only allows the use of medical student documentation; any service billed must still be performed by the physician, as Medicare does not pay for services performed by student

Q2. Do the changes to the medical student documentation guidelines apply to procedures?

A2. No, the recent changes in the CMS E/M guidelines are relevant to only E/M visits which are not time-based.

Although medical students may participate in the performance of procedures, they may not document procedures for billing purposes. For medical student participation in procedures, please see the Program Advisory Billing for Procedures when Medical Students Participate and the related FAQ of the same title.

Q3. CMS Guidelines uses the term “student.” Does this mean APP students are included in this change?

A3. No, CMS clarified that the term student, in this case, means “medical student” and that the changes in the teaching physician rules do not apply to nurse practitioner students, PA students, nurse practitioners, or PA’s.

Q4. What is the definition of a medical student?

A4. Per WA Medicaid, a medical student is an individual who is not an intern or resident, who is not in an approved Graduate Medical Education (GME) program, and who participates in one of the following accredited educational programs: Liaison Committee and Medical Education (LCME), AOA Commission on Osteopathic College Accreditation (COCA), or Association of Accredited Naturopathic Medical Colleges (AANMC).

Q5. Are there billing compliance restrictions on what year level a medical student must be in order to participate in an E/M service and document?

A5. No, there are no such billing compliance restrictions. The teaching physician is responsible for determining the level of participation and involvement of any medical student on a case by case basis.

Q6. What does “physical presence” mean?

A6. Physical presence means the attending physician or resident is in the exam room with the medical student and patient during the performance of the billable portion of the service: HPI, PE, and MDM (physical presence is not required for ROS/PFSH)

Q7. Who can meet the physical presence requirement when the medical student participates?

A7. A resident or teaching physician

Q8. Can a resident edit the medical student’s note and verify its accuracy for the teaching physician?

A8. The resident may correct the medical student’s documentation but the resident may not verify the medical student’s documentation on behalf of the teaching physician. The verification of the medical student’s portion of the documentation is the responsibility of the teaching physician. If the resident edits and/or adds to the documentation of a medical student’s E/M note, the usual teaching physician rules (“key and critical”) for residents do not apply, instead only the rules regarding medical student’s participation apply. Alternatively, the resident may re-document all portions of the service they perform in accordance with Teaching Physician Guidelines.

Q9. Can the teaching physician attest that the participation of the medical student was performed in the physical presence of the resident?

A9. No, if the resident is the only personnel present with the medical student the resident must attest to their own presence during the service.

Q10. Can the medical student see the patient first, write up the documentation, discuss it with the physician and then the physician and medical student see the patient together?

A10. Yes. However, the teaching physician must still complete the two remaining criteria, verification and (re)performance in the presence of the medical student.

Q11. Does the original authorship of the documentation need to be identified?

A11. Yes. In an electronic health record (EHR), it must be identified at a minimum in the audit trail. The medical student should include his/her name and medical student status in the note. For example, “I, Jane Doe MS4, saw and examined the patient in the presence of Dr. Teaching Physician/Resident.”

Q12. Does the medical student need to attest to anything about the documentation?

A12. No.

Q13. Does this change apply to time-based E/M services or critical care services?

A13. No. The provider who performs a time-based E/M or critical care service must perform and document these services him/herself based on the guidelines for each type of service.

Q14. Are there any examples of attestations a teaching physician can use when working with a medical student?

A14. Yes. Teaching physicians do not need to re-document the performance of their own activities, but must document that the verification, presence, and performance requirements were met and an attestation can be used. Examples of appropriate attestations are detailed below. Note: The attestations reflect minimally acceptable documentation; additional information may be added.

Basic Attestation

“I was present with the medical student for the service. I personally verified the history of present illness and performed the physical examination and medical decision making. I have verified all of the medical student’s documentation for this encounter.” Signed & Dated: Dr. Teaching Physician

Basic Attestation with Additional Comment

Attestations When Only the Resident was Present, but the Teaching Physician Completed All Other Requirements.

Resident: “I was present with the medical student for the service.” Signed & Dated: Dr. Resident

Teaching Physician: “I personally performed the physical examination and medical decision making. I have verified all of the medical student’s documentation for this encounter.” Signed & Dated: Dr. Teaching Physician

Q15. Does the medical student’s name need to be referenced in an attestation?

A15. As with residents, if the teaching physician attestation is on the same document that the medical student created and has his/her name, there is no need for the teaching physician to add the medical student’s name to the teaching physician attestation.

Q16. Can SmartPhrases or AutoTexts be created for the teaching physician attestation?

A16. Approved SmartPhrases and AutoTexts have already been created for both EpicCare and ORCA. Please use them.

For Scenario 1 and 2:

Epic = ATTMSCOMPLETE ORCA= Att Stmt – Med Student Complete

For Scenario 3 (Two attestations needed)

Resident: RESMSPRESENCE (Same for Epic and ORCA)

Attending: Epic = ATTMSVERIFY ORCA = Att Stmt – Med Student Verify

Q17. Can medical student documentation be used for billing primary care exception (PCE) encounters?

Q17. No. The teaching physician does not personally verify and re-perform services in PCE encounters which is a requirement to use medical student documentation.

Q18. Can medical students act as scribes?

A18. Medical students may not be engaged as scribes within their medical student role. Please note that UWP physicians who use scribes must strictly follow the C-025 Use of Scribes policy (to be released September 2018).

Q19. What does Medicaid’s comment mean that medical students can document “findings of the teaching physician?”

A19. UWP interprets Medicaid’s language to mean that the medical student in the role of a medical student may change their initial documentation based on guidance provided during the teaching experience while the physician is verifying the history and re-performing the exam and medical decision making.

Remember, the final documentation must represent the work of the teaching physician and the medical student’s participation must be supervised by a teaching physician or a resident in order to use the medical student documentation.

Quick Guide: Medical Student Participation in E/M Services

E/M element	May the medical student perform and document the E/M element?	*Is teaching physician (or resident) presence with the medical student* required for billing the service?**	*Is the teaching physician required to personally verify the medical student’s note?**	*Is the teaching physician required to personally (re)perform* the service?**
Chief Complaint	Yes	Yes	Yes	No
History of Present Illness (HPI)	Yes	Yes	Yes	No
Past, Family, and Social History (PFSH)	Yes	No	Yes	No
Review of Systems (ROS)	Yes	No	Yes	No
Physical Exam (PE)	Yes	Yes	Yes (must also personally perform)	Yes
Medical Decision Making (MDM)	Yes	Yes	Yes (must also personally perform)	Yes

*Verify – make sure or demonstrate the documentation is true and accurate. This includes editing as needed.

References

The text of the CMS guidance can be found at MM10412 – E/M Service Documentation Provided by Students (Manual Update): https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM10412.pdf.

Medicare Claims Processing Manual (MCPM), Chapter 12, Section 100.1.1 https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

MLN Matters MM 10412 E/M Service Documentation Provided by Students (Manual Update) Transmittal https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM10412.pdf

Washington Apple Health (Medicaid) Physician-Related Services/Health Care Professional Services Billing Guide, April 15, 2018, Page 44 https://www.hca.wa.gov/assets/billers-and-providers/physician-related-serv-bi- 20180415.pdf

Related Compliance Policies and Program Advisories

C-022 Teaching Physician Presence and Documentation – Evaluation and Management, Psychiatry, Time-Based, and Certain Other Medical Services

C-025 Use of Scribes

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Dated: June 19, 2018

CMS Medical Student Documentation (Printable PDF)

CMS Documentation FAQ

Medical Student Documentation for Evaluation and Management Services

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