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.<\/p>\n
There are three basic scenarios:<\/p>\n
Scenario 1: The Teaching Physician is present with the medical student for the E\/M service<\/strong><\/p>\n 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\u2019s documentation.<\/p>\n *Verify \u2013 make sure or demonstrate the documentation is true and accurate. This includes editing as needed.<\/p>\n Scenario 2: The medical student sees the patient first without the TP or resident present<\/strong><\/p>\n 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\u2019s documentation.<\/p>\n Scenario 3: The resident is present with the medical student for the E\/M service<\/strong><\/p>\n 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\u2019s note, again after verifying and attesting to it. The resident will attest to their presence with the medical student.<\/p>\n Additional FAQ’s clarifying the CMS update are included below.<\/em><\/strong><\/p>\n Background: <\/strong>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.<\/p>\n Q1. Does this mean I can bill for work performed by a medical student?<\/strong><\/p>\n A1. <\/strong>No, this change only allows the use of medical student documentation<\/u>; any service billed must still be performed<\/u> by the physician, as Medicare does not pay for services performed by student<\/p>\n Q2. Do the changes to the medical student documentation guidelines apply to procedures?<\/strong><\/p>\n A2. <\/strong>No, the recent changes in the CMS E\/M guidelines are relevant to only E\/M visits which are not time-based.<\/p>\n Although medical students may participate in the performance of procedures, they may not document procedures for billing purposes.<\/p>\n Q3. CMS Guidelines uses the term \u201cstudent.\u201d Does this mean APP students are included in this change?<\/strong><\/p>\n A3. <\/strong>No, CMS clarified that the term student, in this case, means \u201cmedical student\u201d and that the changes in the teaching physician rules do not apply to nurse practitioner students, PA students, nurse practitioners, or PA\u2019s.<\/p>\n Q4. What is the definition of a medical student?<\/strong><\/p>\n A4. <\/strong>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).<\/p>\n 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?<\/strong><\/p>\n A5. <\/strong>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.<\/p>\n Q6. What does \u201cphysical presence\u201d mean?<\/strong><\/p>\n A6. <\/strong>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)<\/p>\n Q7. Who can meet the physical presence requirement when the medical student participates? <\/strong><\/p>\n A7. <\/strong>A resident or teaching physician<\/em><\/p>\n Q8. Can a resident edit the medical student\u2019s note and verify its accuracy for the teaching physician?<\/strong><\/p>\n A8. The resident may correct the medical student\u2019s documentation but the resident may not<\/u> verify the medical student\u2019s documentation on behalf of the teaching physician. The verification of the medical student\u2019s 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\u2019s E\/M note, the usual teaching physician rules (\u201ckey and critical\u201d) for residents do not<\/u> apply, instead only the rules regarding medical student\u2019s participation apply. Alternatively, the resident may re-document all portions of the service they perform in accordance with Teaching Physician Guidelines.<\/p>\n Q9. Can the teaching physician attest that the participation of the medical student was performed in the physical presence of the resident?<\/strong><\/p>\n A9. <\/strong>No, if the resident is the only personnel present with the medical student the resident must attest to their own presence during the service.<\/p>\n 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?<\/strong><\/p>\n A10. <\/strong>Yes. However, the teaching physician must still complete the two remaining criteria, verification and (re)performance in the presence of the medical student.<\/p>\n Q11. Does the original authorship of the documentation need to be identified?<\/strong><\/p>\n A11. <\/strong>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, \u201cI, Jane Doe MS4, saw and examined the patient in the presence of Dr. Teaching Physician\/Resident.\u201d<\/p>\n Q12. Does the medical student need to attest to anything about the documentation? <\/strong><\/p>\n A12.<\/strong> No.<\/p>\n Q13. Does this change apply to time-based E\/M services or critical care services?<\/strong><\/p>\n A13. <\/strong>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.<\/p>\n Q14. Are there any examples of attestations a teaching physician can use when working with a medical student?<\/strong><\/p>\n A14. <\/strong>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<\/u>: The attestations reflect minimally acceptable documentation; additional information may be added.<\/p>\n Basic Attestation<\/u><\/strong><\/span><\/p>\n \u201cI 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\u2019s documentation for this encounter.\u201d Signed & Dated: Dr. Teaching Physician<\/p>\n Basic Attestation with Additional Comment<\/u><\/span><\/strong><\/p>\n \u201cI 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\u2019s documentation for this encounter. X-ray results \u2013 lungs clear.\u201d Signed & Dated: Dr. Teaching Physician<\/p>\n Attestations When Only the Resident was Present, but the Teaching Physician Completed All Other<\/u> Requirements.<\/u><\/span><\/strong><\/p>\n Resident<\/strong>: \u201cI was present with the medical student for the service.\u201d Signed & Dated: Dr. Resident<\/p>\n Teaching Physician<\/strong>: \u201cI personally performed the physical examination and medical decision making. I have verified all of the medical student\u2019s documentation for this encounter.\u201d Signed & Dated: Dr. Teaching Physician<\/p>\n Q15. Does the medical student\u2019s name need to be referenced in an attestation?<\/strong><\/p>\n A15. <\/strong>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\u2019s name to the teaching physician attestation.<\/p>\n Q16. Can SmartPhrases or AutoTexts be created for the teaching physician attestation?<\/strong><\/p>\n A16. <\/strong>Approved SmartPhrases and AutoTexts have already been created for both EpicCare and ORCA. Please use them.<\/p>\n For Scenario 1 and 2:<\/u><\/strong><\/span><\/p>\n Epic = ATTMSCOMPLETE\u00a0\u00a0 ORCA= Att Stmt \u2013 Med Student Complete<\/p>\n For Scenario 3 (Two attestations needed)<\/u><\/strong><\/span><\/p>\n Resident: RESMSPRESENCE (Same for Epic and ORCA)<\/p>\n Attending:\u00a0 Epic = ATTMSVERIFY\u00a0\u00a0\u00a0 ORCA = Att Stmt \u2013 Med Student Verify<\/p>\n Q17. Can medical student documentation be used for billing primary care exception (PCE) encounters?<\/strong><\/p>\n Q17. <\/strong>No. The teaching physician does not personally verify and re-perform services in PCE encounters which is a requirement to use medical student documentation.<\/p>\n Q18. Can medical students act as scribes?<\/strong><\/p>\n A18. <\/strong>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).<\/p>\n Q19. What does Medicaid\u2019s comment mean that medical students can document \u201cfindings of the teaching physician?\u201d<\/strong><\/p>\n A19. <\/strong>UWP interprets Medicaid\u2019s 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.<\/p>\n Remember, the final documentation must represent the work of the teaching physician and the medical student\u2019s participation must be supervised by a teaching physician or a resident in order to use the medical student documentation.<\/span><\/strong><\/p>\n \u00a0<\/strong>References<\/u><\/strong><\/p>\n The text of the CMS guidance can be found at MM10412 \u2013 E\/M Service Documentation Provided by Students (Manual Update)<\/p>\n MLN Matters MM 10412 E\/M Service Documentation Provided by Students (Manual Update) Transmittal<\/u><\/u><\/p>\n <\/p>\n Related Compliance Policies and Program Advisories<\/u><\/strong><\/p>\n C-022 Teaching Physician Presence and Documentation \u2013 Evaluation and Management, Psychiatry, Time-Based, and Certain Other Medical Services<\/p>\n C-025 Use of Scribes<\/p>\n *********************************<\/p>\n <\/p>\n","protected":false},"excerpt":{"rendered":" Medical Student Documentation for Evaluation and Management Services 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…<\/p>\n