Ob-Gyn Coding Alert

CMS's deregulation train eases reporting restrictions for student clinicians.

Administrative burdens fuel Medicare's new mantra "Patients Over Paperwork." Since last fall initiatives started rolling out to cut back on this problem. An important policy change suggests CMS remains steadfast in this charge.

Medicare providers have seen this situation in action: A teaching physician works with a medical student as she sees patients throughout the hospital. The medical student documents the E/M service performed - and then the teaching physician has to re-document every element of it afterward. This double-documentation requirement has been a thorn in the side of many practitioners nationwide, but the good news is that CMS has alleviated some of that burden for future student/teacher E/M services.

Here's why:  CMS has released a significant change in its position on medical students participating in E/M services. The policy being changed is part of the Medicare Claims Processing Manual, Chapter 12, section 100.1.1.B, "E/M Service Documentation Provided by Students."

Look at What's Changed

To get a handle on how the new updates, which you can read in MLN Matters article MM10412, will impact how you document, you should first review the current policy, advises Todd Thomas, CPC, CCS-P, president of ERcoder, Inc., in Edmond, Oklahoma.

The history: For many years, CMS has said, "Any contribution and participation of a student to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing." This part of the policy has not changed, Thomas says.

Old way:  CMS has long allowed students to document services in the medical record, but up until now, CMS policy has dictated that teaching physicians can only refer to the students' documentation for the review of systems (ROS) and/or past family/social history (PFSH).

"The student's documentation of physical exam findings or medical decision-making (MDM) could not be used as part of the attending physician's note," Thomas says. "If the student's documentation included history of present illness (HPI), exam, or MDM information, the attending physician had to perform or repeat these elements performed by the student and document the HPI, physical exam and medical decision-making activities of the service."

New way: According to the new policy, "Students may document services in the medical record. However, the teaching physician must verify in the medical record 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."

Therefore, the following are the important features that physicians must note under the new policy, Thomas advises:

• The attending physician must still be at the bedside while the student performs any of the E/M elements.
• The attending physician must personally perform (or re-perform) the physical exam and medical decision-making activities of the E/M service being billed.
• The attending physician may verify student documentation of any or all E/M elements in the medical record, rather than re-documenting information that has already been documented.

No Changes to How Encounter Is Performed

It is important for physicians to understand that this policy change does not affect how the physician and student encounter with the patient is performed, Thomas advises. The change only applies to how the documentation of the encounter can be performed.

"This revised policy seems to streamline the documentation process and ease administrative burdens on physicians, while also adding the necessary component of training of medical students on the proper documentation of E/M services," Thomas says. "This is a very substantial policy change by CMS and could have a drastic change on the documentation workflow if attending physicians choose to use the documentation by the students to support their E/M services."

Retroactive date: The change is effective for services rendered January 1, 2018.

Resources: For more on the update, read CMS Transmittal 3971 at www.cms.gov/Regulations-and-Guidance/ Guidance/Transmittals/2018Downloads/R3971CP.pdf or MLN Matters article 10412 at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10412.pdf.