General Surgery Coding Alert

Question: We have a medical student working with us at our clinic. In patient encounters, the chart note is linked to the supervising physician, and it’s signed by the student and then cosigned by the supervising providers. There is no note that the student saw the patient besides the signing note. Do we need to use better documentation for this situation?

Iowa Subscriber

Answer: CMS issued a revision to the Medicare manual in 2018 that allows teaching physicians to use all student documentation for billable services provided that the teaching physician verifies the documentation. The teaching physician must either personally perform or reperform the physical exam and medical decision making, but he does not need to redocument.

Change: In the past, only the medical student’s documentation of the review of systems (ROS) and past, family, and social history (PFSH) did not need to be redocumented by the teaching physician; now physical exam and medical decision making are added to that list.

Beware: CMS has not changed the requirement that any contribution of the student must be performed in the physical presence of the teaching physician or a resident. If the service is performed in the presence of a resident, then all teaching physician billing rules apply.

There is no rule saying the student has to sign — but of course this would be good practice. In terms of billing, what the teaching physician did is what counts.