Teaching Physicians: No More Re-entering Medical Student E/M Documentation

Teaching Physicians: No More Re-entering Medical Student E/M Documentation

But be sure you step up your game on meeting attestation and signature requirements.

As an ongoing effort to help reduce administrative burden on practitioners, the Centers for Medicare & Medicaid Services (CMS) released an important update for physicians and other clinicians working in teaching institutions. According to CMS’ E/M Service Documentation Provided by Students (Manual Update), transmittal 3971, change request (CR) 10412:

E/M Documentation provided by Students, allows the teaching physician to verify in the medical record any student documentation of components of the E/M services, rather than re-documenting the work. (Manual Update Only)

The change went in to effect Jan. 1, 2018, with a Medicare administrative contractor (MAC) implementation date of no later than March 5. Although the change is welcome for teaching providers, it remains important to properly document the evaluation and management (E/M) teaching encounter to bill for the service and remain compliant.

Evaluation and Management – CEMC

What the Revised Guidelines Say

Here are the details of the revised guidance:

100.1.1 – Evaluation and Management (E/M) Services

(Rev. 3971, Issued: 02- 02- 18, Effective: 01-01-18, Implementation: 03- 05-18)

  1. E/M Service Documentation Provided by Students

Any contribution and participation of a student to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing.

Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or 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 any student documentation of them in the medical record, rather than re-documenting this work.

What the Requirements Mean for Providers

To keep documentation compliant, this revision requires the teaching physician to sign-off, indicating they reviewed the E/M required documentation sections posted by the medical student in the medical record. The teaching physician’s sign off should include the legible full name, credential, date, and attestation supporting their presence during the service (for more information on proper attestations, see the link in the Resource section). If they do not agree or have additional findings after performing their physical exam, the teaching practitioner must properly amend the record.

The teaching physician must also perform the actual physical exam again and document those findings, if they are different from the medical student’s entry. Finally, the teaching physician must amend or modify the medical decision-making entry and plan of care if it differs from the medical student’s documentation.

For more on CMS changes to medical student documentation of E/M services, read the article: “E/M Documentation Can Be Provided by Students Again” in AAPC’s Knowledge Center at: www.aapc.com/blog/40967-em-documentation-provided-by-students-again/

Don’t Let Documentation Get Sloppy

Although this change is a timesaver for teaching physicians and clearly reduces the administrative burden of re-entering the same data the medical student entered, it could be problematic if abused. Potential issues include:

  • Most electronic health records have a time and date stamp recorded when any data is entered. If there is a significant time lapse between the signature stamp of the medical student, the teaching physician auditors may surmise the teaching physician was not present during the services provided by the student. If it is audited by a federal agency or quality improvement contractor, the difference in the signature times could be a red flag. Physical presence is a CMS requirement to bill the E/M service.
  • When questions arise regarding the appropriateness of clinical care, any documentation that supports an unlicensed student performing clinical services absent the physical presence of a teaching physician can become a major legal/compliance issue. Discrepancies such as these need to be reported to the compliance officer.

Examples from CMS of unacceptable documentation include:

  • “Agree with above,” followed by legible countersignature or identity
  • “Rounded, Reviewed, Agree,” followed by legible countersignature or identity
  • “Discussed with resident. Agree,” followed by legible countersignature or identity
  • “Seen and agree,” followed by legible countersignature or identity
  • “Patient seen and evaluated,” followed by legible countersignature or identity
  • A legible countersignature or identity, alone

The documentation above is not acceptable because it does not make it possible to determine whether the teaching physician was present, evaluated the patient, and/or had involvement with the plan of care.


Resource

For more information on what CMS terms “minimally acceptable documentation” for attestations, see CMS Manual System, Pub 100-04 Medicare Claims Processing, Transmittal 3971, CR 10412, Feb. 2: www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R3971CP.pdf

Barbara Aubry

Barbara Aubry, RN, CPC, CPMA, CHCQM, FABQAURP, AAPC Fellow, is a senior regulatory analyst for 3M Health Information Systems (HIS). As a member of the 3M HIS team that creates and manages medical necessity and other coding data, she works directly with CMS on ICD-10 code assignment for their National Coverage Determinations. Aubry has experience in hospital case management and utilization review. She has managed a utilization management department for an HMO, a team of registered nurse auditors, and was the clinical editor of an e-health patient portal. Aubry’s core focus is regulatory compliance. She is member of the Upper Saddle River, N.J., local chapter.

One Response to “Teaching Physicians: No More Re-entering Medical Student E/M Documentation”

  1. Michael Warner, DO, CPC, CPCO, CPMA says:

    Nice article Barbara!
    This is an important policy message that does more than reduce provider burden. Medical students have been increasingly barred from introducing material into medical records. For nearly a decade, medical students have become healthcare observers rather than participants as many health systems and provider offices barred students from documenting anything into the medical record.
    Imagine if medical students only watched the examination of patients until they finally graduated medical school? This is effectively what our system has done in regard to medical record documentation.
    It will be interesting to see if documentation patterns from 2008-2018 medical school graduates differ from the rest of the provider population.
    I like the new policy because medical student training needs to include medical record documentation. In our increasingly data driven society, we need all providers to be proficient in documentation. Training medical students how to document is a good start.
    Thank you for publishing this article!

Leave a Reply

Your email address will not be published. Required fields are marked *