CMS Changes the Rules on Student Documentation

Joyce Will, RHIT, CDIP, CPC, CPCO, CDEO, AAPC Fellow and Physician Services Consultant at Health Information Associates, touches on the upcoming changes CMS has made to these guidelines taking effect next month, in March 2018.

For years, teaching physicians have been following the rule which states: “the teaching physician may not refer to a student’s documentation of physical exam findings or medical decision-making in his or her personal note. If the medical student documents evaluation and management (E&M) services, the teaching physician must verify and redocument the history of present illness, as well as perform and redocument the physical exam and medical decision-making activities of the service.”

All of this changes in March 2018.

CMS has announced a major change to the teaching physician guidelines. The teaching physician will be able to verify documentation of any E/M component, performed by a medical student, rather than re-documenting this work.

This change does not mean the teaching physician is no longer required to perform the HPI, physical exam and medical decision-making components of an E/M service. It also does not change the requirement that any contribution and/or participation of a student must be performed in the physical presence of a teaching physician or resident.

So far, there has been no additional guidance on what will be an acceptable attestation by a resident or teaching physician when the documentation of a student is used to support a billable service.

Practices may want to contact their Medicare Administrative Contractor (MAC) for additional guidance prior to the March 5th effective date for this change.