Wiki Defining "redocument" in an emr

[NHAMBLIN010982]

We are having a discussion on the actual meaning of the word redocument in the CMS reg below. We all know that you cannot count the Med student's documentation beyone PFSH and ROS when billing for E/M in the paper world. The discussion is now translated to the EMR- if the attending doc pulls foward the Med students work (MACRO)- verifies and changes within the EMR does that count as "Redocumenting"?? Remember that Macros are allowed. I think this is a sticky topic and we need clarification- anyone else dealing with this this issue? anyone know where I can get the true answer? I am leaning toward one way but I would like to see everyone elses interp. Please help!!



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.