April 2018

Chart Conundrums: CMS Eases Student Documentation Requirements
By Kathleen O'Brien-Green, RHIT, CCS
For The Record
Vol. 30 No. 4 P. 8

From a documentation standpoint, exciting changes have been happening for teaching physicians. Most notably, the Centers for Medicare & Medicaid Services has revised the Medicare Claims Processing Manual (specifically, chapter 12, section 100.1.1, B. E/M Service Documentation Provided by Students) to allow teaching physicians to verify in the medical record any student documentation of evaluation and management (E/M) service components. The policy change, which eliminates the need for physicians to redocument, was identified by the Documentation Requirement Simplification workgroup as part of a broader goal to reduce administrative burden on practitioners.

In the process of teaching medical students, it is necessary to allow them to document the patient's visit, including the history of present illness, exam, and medical decision making. Prior to the implementation of the new rule, teaching physicians were required to redocument those areas to confirm the medical student's findings, a time-consuming and redundant process for teaching providers. For some time, physicians have argued this additional work is unnecessary.

The new rule, which was officially implemented March 5, allows teaching physicians who are billing for a service to verify in the medical record any student documentation components of the E/M rather than document the same findings. While students may document services in the medical record, teaching physicians must verify all student documentation or findings, including history, physical exam, and/or medical decision making. Teaching physicians must still perform (or reperform) the physical exam and medical decision-making activities of the E/M service being billed, but no longer must they redocument the work.

In addition to verifying student documentation, physicians must continue to provide an attestation statement. When considering attestation statements from providers, keep in mind the following scenarios:

• The teaching physician performs all the required elements of an E/M service without a resident. In this scenario, the resident may or may not have performed the E/M service independently.

• In the absence of a note from a resident, teaching physicians must document as they would an E/M service in a nonteaching setting.

• Where a resident has written notes, the teaching physician's note may reference the resident's note and verify. For payment, the resident's entry must support the medical necessity of the billed service and the level of the service billed by the teaching physician.

The following are examples of accepted documentation for such scenarios.

Example 1
The resident performs the elements required for an E/M service in the presence of or jointly with the teaching physician and documents the service. In this case, the teaching physician must document that he or she was present during the performance of the critical or key portion(s) of the service and was directly involved in the management of the patient. The teaching physician's note should reference the resident's note.

For payment, the composite of the teaching physician's entry and the resident's entry must support medical necessity and the level of the service billed by the teaching physician.

The following are examples of acceptable documentation in this situation:

• Initial or follow-up visit: "I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and the plan as documented in the resident's note."

• Follow-up visit: "I saw the patient with the resident and agree with the resident's findings and plan."

Example 2
The resident performs some or all of the required elements of the service in the absence of the teaching physician and documents the service. The teaching physician independently performs the critical or key portion(s) of the service with or without the resident present and, as appropriate, discusses the case with the resident.

In this instance, the teaching physician must document that he or she personally saw the patient, personally performed critical or key portions of the service, and participated in the management of the patient. The teaching physician's note should verify the resident's note.

For payment, the composite of the teaching physician's entry and the resident's entry must support the medical necessity of the billed service and the level of the service billed by the teaching physician.

The following are examples of acceptable documentation in this situation:

• Initial visit: "I saw and evaluated the patient. I reviewed the resident's note and agree except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs."
• Follow-up visit: "See resident's note for details. I saw and evaluated the patient and agree with the resident's finding and plans as written."
• Follow-up visit: "I saw and evaluated the patient. Agree with the resident's note but lower extremities are weaker, now 3/5; MRI of L/S spine today."

Although the policy change is a welcome respite for teaching physicians, the possibility of unacceptable documentation remains. The following examples can result in incomplete documentation and incomplete/inappropriate billing:

• "Agree with above," followed by legible countersignature or identity;
• "Rounded, Reviewed, Agree," followed by legible countersignature or identity;
• "Discussed with resident. Agree," followed by legible countersignature or identity;
• "Seen and agree," followed by legible countersignature or identity;
• "Patient seen and evaluated," followed by legible countersignature or identity; and
• a legible countersignature or identity alone.

Such documentation is unacceptable because it does not make it possible to determine whether the teaching physician was present, evaluated the patient, and/or had any involvement with the plan of care.

In summary, the changes will impact the documentation required of teaching physicians but have no effect on the requirement that they be physically present during the encounter.

Putting the Changes Into Practice
Organizational cultures apply various approaches to physician training. Typically, however, successful physician training involves applying changes and expectations during live situations such as side-by-side training during clinic and in huddles. Electronic prompting, cheat sheets, follow-up quality checks, and feedback are also traditional ways of ensuring compliance and understanding.

— Kathleen O'Brien-Green, RHIT, CCS, who has more than 20 years of experience in the outpatient facility and professional coding space, serves as the director of coding audit and education for Atos.