Ob-Gyn Coding Alert

Question: We have a student currently at our clinic. Is this correct on documentation rules? The chart note is linked to the supervising physician but signed by the student then cosigned by the supervising providers. There is no note that the student saw the patient besides signing note. Any special documentation that needs to be done in this situation?

Codify Subscriber

Answer: The Centers for Medicare and Medicaid Services (CMS) on Feb. 2, 2018 issued a revision to a Medicare manual that allows teaching physicians to use all student documentation for billable services provided that the teaching physician verifies the documentation. The teaching physician must either personally perform or re-perform the physical exam and medical decision making but does not need to re-document.  

In the past, only the medical student’s documentation of Review of Systems and Past Family and Social History did not need to be re-documented by the teaching physician. CMS has not changed the requirement that any contribution of the student must be performed in the physical presence of the teaching physician or a resident. If the service is performed in the presence of a resident, then all teaching physician billing rules apply.

So there must be physical presence and there is no rule saying the student has to sign (but of course would be good practice). To bill, it is what the teaching physician did that counts.