CMS eases teaching physician documentation rules
Grant Huang, CPC, CPMA
Director of Content
CMS recently released a transmittal tweaking its requirements for teaching physicians to bill for services that involve medical students (not residents, who have earned their MDs). The move is intended to make it easier for the teaching or attending physician to sign off on a student’s note without having to re-document key components of an evaluation and management (E/M) service.
In this article, we’ll take a look at the transmittal, which is Transmittal 3971, released Feb. 2. We will also review the teaching physician guidelines for residents and look at some examples of acceptable attestation statements from the physician, along with some common mistakes that are often made when physicians try to save time.
Tweaking the guidelines
As part of their training, medical students are often tasked with capturing various elements of an E/M service into the medical record to learn how to write medical notes. While Medicare does not pay for services furnished by medical students, it does pay for teaching physicians’ services that involved a medical student being trained who contributed to the documentation.
The previous language prior to Transmittal 3971 states that “the teaching physician may not refer to a student’s documentation of physical exam findings or medical decision making in his or her personal note. If the medical student documents E/M services, the teaching physician must verify and re-document the history of present illness (HPI), as well as perform and re-document the physical exam and medical decision making activities of the service.”
CMS is now effectively eliminating this requirement and saving a significant amount of physician paperwork. Transmittal 3971 amends this existing language in the Medicare Claims Processing Manual, Chap. 12, Sec. 100.1.1, so that it now reads as follows (the italics for emphasis come from the CMS document):
“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.”
Thus where previously the physician had to re-document elements of the history and exam that were captured by the student, now the physician simply refer back to that documentation and say that he or she has reviewed and verified it.
Remember teaching physician rules for residents
Now let’s take a look at the teaching physician documentation rules for residents, which haven’t changed as a result of Transmittal 3971. In order for the teaching physician to bill for an E/M service performed in part or wholly by a resident MD, the documentation must include the following elements:
- An attestation statement from the teaching physician. This statement state that the physician either performed the entire service with the resident observing, or that the physician was physically present with the resident while he or she performed the key components of the E/M service. The attestation must also make it clear that while the resident can perform the key components, the physician participated in managing the patient and has signed off on the assessment and plan portion.
- A timely signature from both the resident and teaching physician. This is standard for any medical record, but with two signatures required, it’s not uncommon to have either the resident or the teaching physician forget to sign and then sign many days after the date of service. CMS hasn’t specified a precise number of days or hours beyond which it no longer considers a signature “timely,” but we at DoctorsManagement recommend that signatures occur no more than 48 hours after the date of service.
- Append modifier GC if required. Medicare and many commercial payers require that modifier GC (This service has been performed in part by a resident under the direction of a teaching physician) be appended to the E/M code for any visit involving some care provided by a resident. Modifier GC does not impact payment, but it is used to certify that the billing physician has complied with the above requirements.
These requirements seem simple enough, but what we often see with resident notes at teaching hospitals is an invalid attestation statement from the teaching physician. Simple attestation statements such as “rounded, reviewed, and agree,” or “discussed case with resident, agree with his/her plan” are used all the time but fail the basic requirement from CMS that the attestation explicitly support the physical presence of the teaching physician during the encounter.
Students vs. residents
Remember, residents have MDs and are licensed to practice medicine, while students are still in medical school after having earned a college degree. A teaching physician can essentially sign off on a resident’s note with an attestation statement so long as he or she was present with the resident during the key components of the E/M service. A teaching physician must perform the E/M service with the medical student only able to contribute to documenting the key components.
However, that contribution couldn’t simply be taken over by the teaching physician; he or she had to essentially re-do all the documentation. Now the physician only needs to state in the attestation that he or she reviewed and verified the student’s documentation, and whether it was accurate (or whether any changes were made), in order to use it in his or her personal note that will support the billed claim.
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