Internal Medicine Coding Alert

Published on Tue Oct 19, 2004 PDF

Question: Do teaching-physician documentation rules cover medical students working in an internal medicine office?

New Mexico Subscriber

Answer: Not exactly. Many people have confused the applicability of the most substantive part of the new teaching-physician guidelines - that the teaching physician need only state what used to be required in the documentation: that he evaluated the patient and agrees or disagrees with the resident's findings.

These revised rules apply only to the supervision of residents and fellows in teaching facility settings. The rules raised considerable concern over how they cover a medical student performing a procedure with the TP physically present. The rules state that a teaching physician can use the medical student's documentation of the medical history, family history, social, and review of systems to support billing.

But if the physician wants reimbursement for the student's work, the physician still has to reference these history elements and confirm the findings with the patient, adding his own HPI and physical exam. The physician must then document those elements again.