Ophthalmology and Optometry Coding Alert

Question: We currently have a medical student working with us at our eye care clinic. In patient encounters, the chart note is linked to the supervising physician, but it’s signed by the student and then cosigned by the supervising providers. There is no note that the student saw the patient besides the signing note. Do any of us need to utilize any particular documentation for this situation? 

Minnesota Subscriber

Answer: In 2018, CMS issued a revision to the 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 reperform the physical exam and medical decision making, but he does not need to redocument.

In the past, only the medical student’s documentation of the review of systems (ROS) and past, family, and social history (PFSH) did not need to be redocumented 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 this would be good practice. In terms of billing, what the teaching physician did is what counts.