There is much excitement but some reservation in the academic practice community about changes to the requirements for student and teaching physician documentation. Before January 1, 2018 a Teaching Physician (TP) could not refer to a student’s documentation of physical exam findings or medical decision-making in his or her personal note. The TP had to re-document the patient’s history as well as perform and re-document the physical exam and medical decision-making. The new ruling from CMS, published in MLN Matters MM10412, “allows the teaching physician to verify in the medical record any student documentation of components of E/M [Evaluation and Management] services, rather than re-documenting the work.”
Some institutions do not permit students to have access to the electronic health records (EHR) system. However, when students do have such access they may now document services in the final medical record. The TP must personally perform (or re-perform) the physical exam and medical decision-making activities, but may verify any student documentation of them in the medical record. There is no change to the requirement that any participation by the student be performed in the presence of a teaching physician or a resident.
At first pass this change would seem to be a great time and work saver for teaching physicians, and most observers hail it as a significant improvement over the previous rule that will greatly reduce the paperwork or EHR burden on physicians in academic practice. However, some clinicians are being cautious. They feel that the rule is not clear enough when considered in the context of defining who is to attest to which part of the documentation when you have a medical student, resident and teaching physician all working together for a particular patient.
Healthcare Administrative Partners recommends that each academic center review its own internal documentation policies and guidelines to decide whether or not to allow the inclusion of student documentation in the medical record. Those policies will have to be modified in consultation with the institution’s compliance department to assure that the record is clear about the level of participation of each party, including:
- The TP will have to clearly state that he or she has verified the documentation entered by the student.
- The TP will have to clearly state that he or she personally performed the physical examination and medical decision-making of the E/M service.
Clearly, this rule change will not allow the TP to become a ‘rubber stamp’ of the student’s work! The TP will still have the responsibility for anything entered by the student, and he or she is still required to be ‘hands on’ during the patient’s exam. TPs always have to be aware of potential medical/legal risks when accepting a medical student’s documentation into the chart, and their continued diligence in the review and acceptance of students’ notes will be essential.
Documentation is crucial to allow coding for the highest level of reimbursement. HAP provides our coding services clients and revenue cycle management clients with ongoing review and feedback about their documentation to assure them of maximal reimbursement.
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