Change Request (CR) 10412 revises the Medicare Claims Processing Manual to allow the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work. Make sure your billing staffs are aware of the changes.
What does this mean to you?
The Centers for Medicare & Medicaid Services (CMS) is revising the Medicare Claims Processing Manual, Chapter 12, Section 100.1.1, to update its policy on Evaluation and Management (E/M) documentation to allow the teaching physician to verify in the medical record any medical student’s documentation of components of E/M services, rather than re-documenting the work.
According to CMS Change Request 10412, students may document services they provide in the medical record. However, the teaching physician must verify 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.
Our recommended approach
We asked Lindsey Baldwin at CMS what TP documentation is required. Her response is below:
There is no additional sub-regulatory guidance at this time beyond what is stated in the revised manual guidance. You may want to reach out to your local Medicare Administrative Contractor (MAC) for additional guidance.
MedData recommends continuing with the CMS 2017 guidance (the medical student is only allowed to document the PFSH and ROS) until CMS issues further clarification on requirements.
Initially, the potential benefit is that the provider is not required to re-document services already provided. However, combining the Medical Student, Resident, APP and Teaching Physician documentation, as well as defining who is to attest to what part of the documentation and what documentation from the TP is required for different levels of providers, is problematic. There are obvious risks, particularly medical/legal, when accepting a medical student’s documentation into your chart.
MedData will provide additional recommendations when CMS clarifies their position.
MedData Disclaimer – This document is provided for general informational purposes only and is not intended as legal advice. The providing of the information in this document is neither intended to establish an attorney-client relationship nor to expand the existing contractual relationship with MedData. MedData would recommend that you consult with your own internal legal resources before taking any action in reliance on this information.