Medicare recently updated the guidelines and requirements for using medical student documentation to support a provider’s coding. Previously, teaching providers could not use any student documentation, except for the review of systems and past medical/family/social history, to support their level of service. Teaching physicians can now use medical student documentation to support the code that accurately reflects the services provided.
Please see below for the link to the new Intermountain Healthcare policy and a summary of the physician’s responsibilities when using medical student documentation.
Physician Responsibilities for Using Medical Student Documentation:
- Personally confirm verbally with the patient every history of present illness (HPI) element obtained by the student.
- Personally perform or reperform the physical exam.
- Perform the medical decision-making
- Carefully and thoroughly review the medical student’s documentation for accuracy and make necessary changes.
- If the physician has completed the above, then add the following attestation statement at the end of the note: “I , (physician name), was present with a medical student who participated in the documentation of this note. I saw and evaluated the patient and discussed the case with the student. I reviewed the note and agree with the content and plan as written and have verified all sections documented by the student as noted above.”
If the physician does not perform each of the above bulleted points, then the medical student’s documentation cannot be used to support the physician’s CPT code.
Per Medicare, this change applies only to medical students. Physicians and APPs who act as preceptors to APP students must document their own notes. Only the review of systems and past medical/family/social history can be used from the APP student documentation.
Access Intermountain's Medical Student Medical Record Documentation Policy here.
Thank you for your time. Please reach out to Christopher Chandler, Professional Documentation and Coding technical manager, if you have any questions.