Wiki Billing with Medical students dictation??

[l1ttle_0ne]

This is the first time I've come across this. So I'm wanting other's opinion. Our physician has a medical student he supervised. He did a very short note, and the medical student did a very detailed note. Am I able to use the medical students dictation in addition to my physicians dictation since he supervised her?? This is not a teaching school, and this is the first time any of our physicians has done this. Any help you can provide would be great!! Thank you.

This is my doctor's note.

I have personally seen and examined this patient.


I supervised **** (Medical student) in the assessment of, and synthesis of the plan for, this patient.


I formulated the essential elements of the surgical plan with ****.


I discussed the pertinent risks, benefits and alternatives with the patient and her daughter and feel it appropriate to offer a laparoscopic cholecystectomy to be performed tomorrow morning if the patient is medically clear/stable.




We had a discussion regarding this plan including:


Procedure:
Laparoscopic cholecystectomy with cholangiogram, possible conversion to an open cholecystectomy


Alternatives:
Continued cholecystitis, possible (albeit remotely so) biliary pancreatitis and its risks (pain, possible death), possible choledocholithiasis and its risks (cholangitis, jaundice).


Benefits:
Treatment of underlying cause of pain and restoration of normal diet.


Risks (Including, but not limited to):
Bleeding with a remote possibility of transfusion, injury to the extrahepatic biliary tree (ranging from leak to stricture to complete disruption), retained stone in common duct


Complications (Including, but not limited to):
Organ damage, continued pain, possible fatty intolerance.


After a discussion of the above, the patient gives verbal consent to the procedure. A separate written consent will be obtained.

 

[MikeEnos]

Here is what Medicare says in the Medicare Claims Processing Manual Chapter 12 Section 100.1.1 Paragraph B

B. 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 documentation of an E/M service by a student that may be referred to by the teaching physician is limited to documentation related to the review of systems and/or past family/social history. 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 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.

Emphasis mine. I hope that helps answer that question.

 

[l1ttle_0ne]

Here is what Medicare says in the Medicare Claims Processing Manual Chapter 12 Section 100.1.1 Paragraph B



Emphasis mine. I hope that helps answer that question.

Thank you for your help. I will have to contact my doctor, and have him dictate his own physical exam.

Thanks again!