Medical Student Note Billing

Medicare allows teaching physicians to utilize medical student documentation to support billing evaluation and management (E&M) services.

The following criteria must be met when billing for services documented by medical students:

  • Services must be E&M services (diagnostic and therapeutic services are prohibited).

  • Medical students may document any and all components of the E&M service.

  • E&M services must be performed in the physical presence of a teaching physician or resident.

  • The teaching physician must personally perform (or re-perform) the physical exam and medical decision-making.

  • The teaching physician must verify medical student documentation (residents are prohibited from verifying student documentation).

  • Proof of teaching physician verification should be documented using an attestation.

Workflow Examples

Ambulatory Workflow

• Student independently performs interview and basic exam

• Student presents findings to preceptor (ideally in front of the patient)

• Preceptor clarifies, confirms key history, (re)performs exam and reviews assessment and plan (with student present)

• Student writes note using a regular progress note (Do NOT use Student Note type with red banner)

• Preceptor addends student note, using system smart phrase (see below) and edits as needed, and submits billing.

 

Inpatient Workflow Independent Student History and Exam, Not Directly Observed

• Medical student obtains history and performs exam with patient independently

• During bedside rounds, medical student presents the history and exam he/she obtained in presence of preceptor

• Teaching physician/preceptor verifies the key elements of the exam and confirms medical decision-making of the student/team

 

Inpatient Workflow Directly Observed by a Resident

• Resident supervises medical student obtaining physical exam

• Medical student presents the patient’s history and physical exam to the teaching physician (outside room or at bedside)

• Teaching physician verifies history, physical exam, and reviews medical decision making ideally in the presence of the student

 

Inpatient Workflow Directly Observed, No Resident

• Teaching physician supervises medical student, performing physical exam, verifies key findings, and confirms medical decision making

 

Confirming the Level of Service (LOS) Evaluation & Management (E&M) Elements

• All elements the student performs should be reviewed

• The teaching physician should perform the history & physical exam elements to support optimal patient care and the level of service commensurate to the billing

System Smart Phrases

.TPMEDSTUDENT

Attending Attestation:
I have seen and examined the patient on *** (date) at approximately *** (time).
I was physically present with the medical student who participated in the documentation of this note. I personally performed the physical exam and medical decision making. I have reviewed, verified, and agree with the medical student documentation including history, physical exam, medical decision making and findings with the addition and/or exception of the items documented by me below.
Additional comments:

.TPMSATTENDING

Attending - Medical Student - NO RESIDENT

I was physically present with the medical student who participated in the documentation of this note. I personally performed the physical exam and medical decision making. I have reviewed and agree with the medical student documentation including the history, physical exam, medical decision making and findings, with the addition and/or exception of items documented below.

 

.TPMSATTENDINGWITHRES

Attending - Medical Student - WITH RESIDENT

I have reviewed and agree with the medical student and resident documentation. I personally performed the physical exam and medical decision-making. I have reviewed and agree with the medical student documentation including the history, physical exam, medical decision making and findings, with the addition and/or exception of items documented below.

Important Information

Type of note template:

a) Student will use a regular note type, i.e. progress note, H&P note, if you want to use their note for billing

b) Student should use the ‘student note’ only if you do not want to use their note for billing

 

Attending or the resident should communicate with the student and confirm whether a billable note template or non-billable note template should be used, e.g. progress note vs. the nonbillable student-note type

Irrespective if billable or non-billable, the student should assign attending to cosign each completed note and attending reviews student documentation and provides feedback.

 

Compliance Essentials for Use of Student Documentation

  1. Physical Presence–2 options:

    1. Teaching Physician preceptor (or Resident) was physically present in the room when the student examined the patient; Or

    2. Teaching Physician preceptor verified the student documentation with the patient in the physical presence of the student.

  2. Verification: Teaching Physician preceptor personally verified the student documentation relied upon for the level of service billed.

  3. Examination: Teaching Physician preceptor performed the exam (if part of the billable service) and supplied the medical decision making.

  4. Use appropriate system smartphrase (see above)




Updated: June 2024