As of March 5, physicians no longer have to write their own notes in addition to notes created by students, residents or fellows during patient examinations; instead, providers will only have to verify information documented by the student. Early last month, the Centers for Medicare and Medicaid Services (CMS) reversed the Obama administration policy that prohibited providers from using medical student’s notes as a part of a patient’s official medical record. Prior to this change, teaching physicians were required to document relevant information on each critical or key element of each billable service, even if the student, resident or fellow had already documented the same information accurately.
What It Means for Physicians
Keep in mind the new policy does not mean a lack of supervision. The CMS has stated that under the new policy, the teaching physician is still required to personally perform (or reperform) the physical exam and medical decision-making activities of the evaluation and management (E/M) service being billed, but they no longer have to redocument the same work; they only need to verify any documentation by students, residents or fellows of billed services in the patient’s medical record. At a time when providers are overtaxed with paperwork and other administration burdens, this change will help decrease physician workload and burnout.
The Importance of Correct Documentation
Understanding the correct way to document teaching physician participation during a patient visit with a student, resident or fellow is key to billing and coding compliance. Although the policies may be tricky to sort out, properly documenting these interactions will help ensure your students, residents, fellows and faculty avoid coding errors and billing mistakes. These entries in the medical record must support the E/M services’ level of care and the medical necessity of the service billed.
Need to Know More?
For more information, or if you have questions on coding and documentation compliance and guidelines, contact the ACR Practice Management Department at [email protected].