Coding, Classification & Reimbursement

Documentation requirements for medical students

Greta A. Ryan, RHIA,CCS,CCS-P,AHIMA Certified ICD-10 Trainer11 days ago

Janice R. Noller, BS in Medical Record Science,RHIA,CDIP,CCS11 days ago

  • 1.  Documentation requirements for medical students

    Posted 03-17-2015 16:26
    Hello all,

    I am a student currently finishing my practicum and working on my capstone project. If anyone can help me with some information or point me in a direction that I have not thought of I would greatly appreciate it. The hospital that I am currently working my practicum hours will soon be getting a physician residency program and I have been tasked with finding information that would be helpful to the HIM department. The questions that I am looking to answer deal with the medical students making entries in the medical record & if the do what process is followed with that. How is a query handled? Does it go to the supervisor or the student? Would anyone be willing or able to share any policies & procedures? 

    Thank you for any assistance! I appreciate it!!

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    Marchelle Leach
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  • 2.  RE: Documentation requirements for medical students

    Posted 03-18-2015 17:22
    Medicare does not recognize med student's documentation. Everything must be documented separately by the supervising physician. A statement saying "I have reviewed this documentation and I agree" or something similar does not suffice. I would send a query to the supervising physician since you cannot code off of a student's documentation.

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    Melissa Still, CCS
    Inpt/outpt/RHC coder
    Iowa
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  • 3.  RE: Documentation requirements for medical students

    Posted 03-18-2015 20:07

    Thank you Melissa for your help, it is greatly appreciated!!
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    Marchelle Leach
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  • 4.  RE: Documentation requirements for medical students

    Posted 12 days ago
    ​Is there a coding clinic that defines when we can or cannot use medical student documentation.

    The physicians I am working with would like the medical student to write the note and they would then co-sign the note.

    I have always been told that, as a CDI, I should not take information from a medical student's note - the attending needed to include the diagnoses and plan of care.

    Please let me know what the coders are and are not able to code from in regards to medical students. (with references so I can present this to the physicians.)

    Thank you
    Terry

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    Therese Peyton
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  • 5.  RE: Documentation requirements for medical students

    Posted 11 days ago
    ​The CMS is a great source for information on teaching physicians, the GME program, and what residents and medical students can document.  In February 2018 the CMS updated the E/M documentation by medical students information.  I've attached the website.  From what you are describing it sounds like the physician is using the medical student as a scribe.  I would do a search on the CMS website using medical student as a scribe.  They have specific verbiage recommendations for that scenario.

    https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10412.pdf

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    Allison Evans, RHIA
    Coding Manager
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  • 6.  RE: Documentation requirements for medical students

    Posted 11 days ago
    Thank you - as we all know things are always changing..... I'll check it out.

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    Therese Peyton
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  • 7.  RE: Documentation requirements for medical students

    Posted 6 days ago
    I don't understand the CMS Guidelines on student documentation.  Is it OK or not?  What documentation is required to use the student documentation.  Very confusing!!!  What is everyone's interpretation??
    Thanks for your help.

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    Nelda Laskey RHIT
    Coder/RAC Coordinator
    Kearny County Hospital
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  • 8.  RE: Documentation requirements for medical students

    Posted 5 days ago
    ​I interpret the guideline to mean that any documentation by the medical student can be used as long as the supervising MD attests that he/she personally performed the key elements and agrees with what the medical student has documented.  It can't just be a co-signature.

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    Greta Ryan, RHIA, CCS, CCS-P
    Coding & Compliance Analyst
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  • 9.  RE: Documentation requirements for medical students

    Posted 5 days ago
    ​Hi Nelda,

    It does sound pretty confusing.  But here is my interpretation.

    OLD:  Student would document; provider must perform each elements of E/M (aside from PFSH, ROS) and re-document everything in his/her own words.

    NEW:  Student would document; provider would have to verify the accuracy of the information (through performance of "key elements" of E/M (Exam, MDM), but would not have to redocument any of the student's notes unless he/she disagree with it.

    One thing I would be careful of:

    Most payers including CMS required Chief complaint and history of present illness (HPI) to be personally documented by the provider or NPP.  With this new rule, it may appear that students (whether MD students or MA or scribes) can now document this.

    Any other thoughts?

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    William Wong, CHC, CHPC, CCS, CPC, CPMA, CDEO
    AHIMA Approved ICD-10 CM/PCS Trainer
    Compliance Analyst
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  • 10.  RE: Documentation requirements for medical students

    Posted 5 days ago
    This is what the general consensus is now at the facility I am working with.    CDI and Coding can use med student documentation if there is an attestation statement from the teaching physician verifying the information or making changes as needed.

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    Therese Peyton
    RN CCDS
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  • 11.  RE: Documentation requirements for medical students

    Posted 11 days ago
    ​Until very recently, the attending physician had to personally document the history of present illness, exam, and medical decision-making components even if the medical student documented these as well.  CMS recently issued Transmittal 3971 stating the following:

    Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.

    Now, if I had a note documented by a medical student with an attestation that the supervising physician had personally performed the services and verified what is in the medical student note, I would code any diagnoses documented in the assessment.  There must be an attestation from the physician, not just a co-signature

    This update is in the Medicare Claims Processing Manual Chapter 12 Section 100.1.1.



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    Greta Ryan, RHIA, CCS, CCS-P
    Coding & Compliance Analyst
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  • 12.  RE: Documentation requirements for medical students

    Posted 11 days ago
    THank you - I knew there were changes, just not sure how this all playedinto the final coding of things.  I appreciate your response.  This is very helpful

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    Therese Peyton
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  • 13.  RE: Documentation requirements for medical students

    Posted 11 days ago
    Just a comment - The Medicare Manual was recently updated to allow teaching physicians to use the medical student notes - see below in italics.  However, I agree with Melissa that the Claims Processing Manual does state that the physician must do the work, but if the medical student has documented appropriately, the physician doesn't have to re-document.  I underlined the wording that has been revised:

    Medicare Claims Processing Manual
    Chapter 12 - Physicians/Nonphysician Practitioners
    100.1.1 - Evaluation and Management (E/M) Services (Rev. 3971, Issued: 02- 02- 18, Effective: 01-01-18, Implementation: 03- 05-18)
    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 teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.


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    [Janice] [Noller, RHIA, CDIP, CCS]
    [Inpatient Coding Educator][University of Utah Health Care][Salt Lake City][Utah]
    [Janice.noller@hsc.utah.edu]
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  • 14.  RE: Documentation requirements for medical students

    Posted 11 days ago
    Thank you for this information - the specifics are what we are looking for!

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    Therese Peyton
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  • 15.  RE: Documentation requirements for medical students

    Posted 11 days ago
    ​We recently received the information documented below.  We have been instructed pursuant to this change that the attending can indeed co-sign a medical student's note without have to re-document the content. Is there clarification regarding the impact on current practice based on this new directive?

    CMS eases guidelines on medical student documentation

    To help reduce the burden of documentation on physicians, the Centers for Medicare and Medicaid Services (CMS) released new guidelines expanding the information medical students can document in the EMR and eliminating the need for teaching physicians to re-document the information.

    What's more, medical student documentation can now be counted toward Evaluation and Management (E/M) billing. Thus, if you, as a teaching physician, are supervising medical students or any advance practice professionals who are documenting a patient exam, medical decision making and other components of a patient encounter, the E/M services can be billed to Medicare.

    Please see link to MLN dated March, 2018

    https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Teaching-Physicians-Fact-Sheet-ICN006437.pdf

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    Indra Osi
    Enterprise Director Hospital Coding and Reimbursement
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  • 16.  RE: Documentation requirements for medical students

    Posted 11 days ago
    Thank you , I saw this but wasn't sure how it would play out in the big picture and the IP coding.  I appreciate your time to respond.

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    Therese Peyton
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  • 17.  RE: Documentation requirements for medical students

    Posted 11 days ago
    ​Hello!

    Here is another source for you to use. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R3971CP.pdf

    This is a copy of the official CMS Transmittal.


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    Lawrence Barr
    President
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  • 18.  RE: Documentation requirements for medical students

    Posted 11 days ago
    Thanks!  I will look into all these resources - I appreciate your time.

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    Therese Peyton
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