Medicare Compliance & Reimbursement

Integrate medical student E/M documentation policy changes with this advice.

The new updates to E/M documentation by medical students promise to improve the notetaking processes and procedures across the spectrum of healthcare venues. Now is a great time to reevaluate your protocols and put a practice-wide plan in place about how to successfully take advantage of this policy change in your office.

When creating your plan, take the following into consideration before implementing any changes regarding this policy, Todd Thomas, CPC, CCS-P, president of ERcoder, Inc., in Edmond, Oklahoma advises:

• The attending physician must be at the bedside with the student and must personally perform (or re-perform) the physical exam and medical decision-making activities.
• It must be the attending physician at bedside with the student. It cannot be a resident.
• It must be the attending physician that performs (or re-performs) the physical exam and medical decision-making activities. It cannot be a resident.
• The entries into the medical record by the student must be identifiable as such. In some facilities, this may involve assigning EHR user names to students.
• Students may need additional education on the correct use of the EHR as well as appropriate documentation of E/M services.
• Attending physicians may need additional education to understand performance and documentation requirements related to medical student's participation in the E/M service.
• In facilities that use templates or macros for the teaching physician attestations, there will need to be an additional attestation(s) created to indication presence during a student's performance of any E/M elements and confirm verification of the student's documentation.

Tip: This policy change may be a preview of things to come, Thomas surmises. "There have been rumblings of changes to the E/M guidelines and other steps to streamline the documentation process," he said. As CMS says in Transmittal 3971 regarding this update, "This policy change was identified by the Documentation Requirement Simplification workgroup. This change is part of a broader goal to reduce administrative burden on practitioners."