CMS Allows Medical Student Documentation for Billable Services—But Proceed With Caution

Analysts See Risk and Reward: Less Paperwork, but Increased Potential Liability

The Centers for Medicare and Medicaid Services (CMS) recently issued a revision to the Medicare manual that everyone should be familiar with: Teaching physicians can use student documentation for billable services. But the ruling, which was quietly made, comes with plenty of caveats, so if you intend to put it to use, you need to be familiar with the provision’s fine print.

Medical billing consultant Jill M. Young outlines the CMS ruling, the effective date of change, the level of supervision required, and how to incorporate medical student documentation into patient records in her live webinar for Audio Educator, “Compliant Use of Medical Student Documentation In a Patient’s Permanent Record – Medicare’s Policy Change.” This new CMS rule can be used to your advantage if you know how to work the system.

Rule Change Could Save Time—but Not Everyone Is Buying It

The rule change was part of a brief update issued in early February titled “Medicare Claims Processing.” Now, teaching physicians can “verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work.”

Good news: This revision should relieve physicians of some significant paperwork burdens—as long as the student’s contribution is overseen by a teaching physician, said the American Association of Medical Colleges (AAMC). In the past, the teaching physician had to re-document everything except “the medical student’s documentation of Review of Systems and Past Family and Social History,” the association reported. Now, such re-documentation is unnecessary unless the student performed the service in the presence of a resident—“then all teaching physician billing rules apply,” the AAMC stated.

Beware: Not everyone is jumping on board with the documentation change, however. MedData said the ruling was too vague to press ahead with wholesale billing process revisions. “There is no additional sub-regulatory guidance at this time beyond what is stated in the revised manual guidance,” Lindsey Baldwin, a CMS payment expert, told the site. “You may want to reach out to your local Medicare Administrative Contractor for additional guidance.”

Writing for MedData, Dr. Hallet Watz also expressed concerns about undefined criteria, such as who can attest that the documentation is sufficient and what kinds of documentation are actually needed. “There are obvious risks, particularly medical/legal, when accepting a medical student’s documentation into your chart,” he wrote.

Big Risks: Errors, Conflicting Accounts & Liability

Others, however, are more bullish on the change’s impact. Dr. Ronald Hirsch, writing for RACmonitor, said any health system that uses medical students should see a big benefit.

“With this change to the regulation, while the teaching physician must of course verify all the information in the medical student’s notes and must perform the physical examination and the medical decision-making, they no longer have to re-document all these elements,” he wrote. “They can simply indicate in the record that they verified the medical student’s documentation, and of course made any corrections or additions appropriate.”

The smart strategy, of course, is to proceed with caution. Facilities will need to weigh the risks and benefits and create accountability plans for detecting and correcting errors, advised Robert L. Altman in an article for AAP News.

“The unique risk that medical students pose is the need for the supervising physician to carefully review the note and correct inaccuracies before it is finalized,” Altman wrote. “Liability exposure occurs if the attending does not notice erroneous information in the medical student’s note and it becomes part of the permanent record or if the attending ignores something that is documented accurately but is concerning. Conflicting accounts within the medical record can create doubt and potential liability risk.”

That means, said Young, that billers, auditors, officer managers, and teaching institution physicians need to be aware of both the benefits and the potential liabilities of this potentially big change.

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