In the past, the notation of medical students was not considered enough to count as the patient’s official documentation during evaluation and management (E/M) services. Though students must make rounds and see patients along with their mentoring physicians, they have not been allowed to perform any documentation role besides that of scribe. In other words, they could make note of anything the physician or patient said, but the physician would later have to rewrite the notes in order for them to count as official. This rule held firm even when the medical student’s notes were completely valid and even when the physician was simply rewriting the student’s exact words.
On March 5th, however, that rule will finally change. Thanks to a new update from the Centers for Medicare and Medicaid Services (CMS), teaching physicians can now simply verify a medical student’s E/M work instead of rewriting it from scratch. Under this new rule, the physician must verify all parts of the E/M service (history, physical exam, medical decision making) before signing off on the student’s work.
So what does this mean for medical coders? In a nutshell, it means there is a possibility that they may see more errors, discrepancies, or gaps in documentation. Medical students are still relatively new to the field, so there is every chance that they will make a few mistakes or forget to include important pieces of documentation as they go. Though the teaching physician is supposed to review the notes and adjust them accordingly, they are only human as well, and skimming over a page of information is vastly different from having to go through it and rewrite each word. Coders are the last line of defense, so when this new rule goes into effect, they will need to be extra diligent about reviewing documentation from medical students and querying the physician when the need arises.