Student Documentation: The Good, Bad, and Ugly
3/13/2019
Student Documentation: The Good, Bad, and Ugly
Michelle Densley, University of Utah Health
Brenda Mickow, Mayo Clinic
Disclaimer
This presentation does not represent the University of Utah Health or Mayo Clinic, and is the sole opinion of the presenters. This presentation does not represent legal interpretation, guidance, or advice.
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Billing and Coding Personnel
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7 Elements of an Effective Compliance Program
? Governance
Leadership, oversight, accountability
Establishing clear
expectations
? Policies ? Education ? Communication
? Reporting ? Investigating ? Monitoring ? Auditing
Following up on adherence to standards & expectations
Corrective Action -
Employees
? Enforcement ? Discipline
? Detection ? Prevention
Corrective Action - Processes
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How to Use a Student
Resident
Advanced Practice Clinician (APC)
Attending Physician
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Types of Students Definitions
Fellow, Resident, & Intern
? Individual who participates in approved graduate medical education (GME) program, or ? Physician not in approved GME program but authorized to practice only in hospital setting
Medical Student
? Individual who participates in accredited educational program (e.g., medical school) that is not approved GME program
? Never considered intern or resident ? Medicare does not pay for any service furnished by students
Other Students
? Nurse Practitioner ? Physician Assistant ? Psychology ? Social Worker ? Therapist
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Medical Student Participation CMS Guidelines
? Any contribution and participation of student must be performed in the physical presence of teaching physician/resident
? Exception: Review of Systems and Past, Family, Social History
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Other Students
? APC (i.e., Nurse Practitioner, Physician Assistant), Psychology, Social Worker, Therapist
? CMS is silent on guidance for other students
? Provider participates in the services with the student
? Provider documents the services performed with the student
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Services with Medical Students CMS Documentation Guidelines
Students may document in medical record
Teaching physician/resident must verify student documentation including history, physical exam
and/or medical decision making
Teaching physician/resident must personally perform (or re-perform) the physical exam and
medical decision making
Teaching physician may verify student documentation rather than re-documenting
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Considerations
? Professional Licensing
? States do not license medical students ? States may not license other types of students
? Training Programs ? Insurance Companies
? Medicare, Medicaid, and Commercial
? Specialty Societies ? Other State and Federal Requirements ? Facility Policies and Procedures
? Medical Staff By-Laws
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