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CMS Transmittal 3971 allows teaching physicians to verify a student’s assessment of a patient, but doesn’t require them to re-document the entire encounter.

Regulations

CMS Eases Teaching Physicians' Documentation Responsibilities

  • Sandy Giangreco Brown
  • 4/9/2018

In the past, teaching physicians were required to re-document all the work performed and documented by students. Recently, The Centers for Medicare and Medicaid Services (CMS) released a statement regarding teaching physicians and their documentation practices. This manual update became effective March 5, 2018, and allows medical students to document the services they perform in the medical record (electronic or on paper), and then the teaching physicians need only verify the student’s documentation.

Easing the burden on teaching physicians

CMS’ intent is to lessen the burden on teaching physicians by eliminating the duplication of work that has already been done by students. (This change affects medical students, not residents.)

According to CMS Transmittal 3971, students are allowed to see the patient and perform the exam and all of the other elements of the patient encounter, including the patient history and the medical decision making. The student can then document the encounter in the patient’s record, and the teaching physician can simply verify the student documentation by performing or re-performing the exam and verifying the rest of the student’s documented assessment. However, the teaching physician is not required to re-document it.

This is a significant change for physicians in academic teaching facilities; however, it is still imperative that the provider be present during the patient encounter itself.

Teaching physicians should proceed with caution

Ultimately, this change should be a time saver for teaching physicians, providing them more time to catch up on documentation, make rounds, and attend to many other daily demands. However, before fully embracing this change, physicians should also consider the potential legal impact — students don’t have a license yet, and the teaching physician is the licensed provider responsible for billing for these services.

How we can help

Modifications to documentation guidelines like this can financially and operationally impact your practice. CLA’s health care professionals are immersed in the industry and can help you fully understand, navigate, and adapt to these changes.