Medicare only allows the teaching/billing physician to be credited for student work that involved obtaining and documenting information regarding the ROS and PFSH, and this can be done in the absence of the TP. Any other work performed by a student must be performed in the presence of the TP, and even then, no credit is given for it. It must be re-performed and re-documented by the TP. The fact that a resident observed the student while doing unapproved portions of the service (like the physical exam) is irrelevant for Medicare teaching physician policy. It wouldn't have mattered even if the TP would have been in the room. A student simply can not perform a physical exam and document this in the record and use this towards the teaching physician's E/M level.
The process that you described, where the student performed more of the service than is allowed by Medicare, had their note approved and signed by a resident, who then had their note approved and signed by the TP is not uncommon, but it is not compliant under Medicare's teaching physician guidelines.
Seth Canterbury, CPC, ACS-EM
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