Orthopedic Coding Alert

Question: Our physicians often complain about having to re-document the elements of evaluation and management (E/M) services they perform, even though their medical students have already documented them. Is there a way around this?

Wisconsin Subscriber

Answer: Yes, fortunately there is now a way around at least part of the documentation requirements.

Background: 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.

If the student's documentation included history of present illness (HPI), exam, or medical decision-making (MDM) information, the attending physician had to perform or repeat these elements performed by the student and re-document the HPI, physical exam and medical decision-making activities of the service.

New way:  According to a new CMS policy, which went into effect Jan. 1, "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:

• 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.

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