Billing Compliance and Medical Student Documentation
Frequently Asked Questions
- What was approved?
- When is the policy change effective?
- How will the policy effect who performs and documents the service?
- Why is the policy being changed?
- Who decided to make this change?
- How will CareWeb change to accommodate this policy?
- Is there training available?
- What do I need to do before the effective date of May 12?
- What if a non-physician provider (NPP) provides a billable service in conjunction with a medical student?
- Does this policy apply to PA students or nursing students?
- Where can I find more information?
- Who should I contact with questions?
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What was approved?
The FGP Board approved a new Billing Compliance and Medical Student Documentation Policy. Effective May 12, 2008, medical students may not be used as scribes for billing purposes.
- Medical students may continue to document in CareWeb using the Medical Student Worksheet found in Create Documents.
- Attending physicians are responsible for ensuring proper documentation for billing purposes.
- If only a student note is available; the attending physician must personally document his/her service.
Students may continue to write notes in the chart to document patient care and to enhance their education. However, in every case where billing occurs, there must be an additional physician (faculty or house officer) note. Billing will occur only from the note of the physician. The full policy is available here.
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When is the policy change effective?
The policy is effective May 12, 2008. System changes are being made and will be available for your use on May 12, 2008.
If you use a medical student scribe template, you must discontinue using it on May 12, 2008.
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How will the policy effect who performs and documents the service?
- A physician (faculty or house officer) must provide the billable service and personally document his/her service.
- Faculty may still add an attestation of presence to a house officer’s note, but must personally document the billable service if only a student note is present.
- Medical students are not allowed to serve as scribes for billable services.
Step-by-step instructions are now available..
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Why is the policy being changed?
The new policy is being implemented in order to clarify compliance with federal regulations and other payor requirements regarding documentation for billing of professional services. We recognize that compliance with this policy will take effort and that it represents a significant change for some services. We are working together to continue to strike an important balance between supporting medical student documentation for educational purposes and complying with federal requirements for billing of professional services.
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Who decided to make this change?
The Faculty Group Practice (FGP), the Professional Billing Reimbursement Compliance & Education Office and the Medical School have worked together to address medical student documentation and professional billing requirements. The FGP Board reviewed and approved the policy earlier this year. HIM, MCIT CareWeb Team and other UMHS administrators were engaged to design and implement required system changes and policy changes.
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How will CareWeb change to accommodate this policy?
To facilitate compliance with this policy, physicians and medical students will use the new Medical Student Worksheet in CareWeb to record their notes.
Medical students will use the Medical Student Worksheet available in Create Doc to document their notes. They will send their Medical Student Worksheet to the House Officer or Attending Physician’s Notifications Inbox using the Create Doc “Save and Forward” button.
Physicians (Faculty and House Officers) have two options for documenting their notes:
- Create Doc – Physician completes the top portion of the template with his/her own HPI, Exam and Assessment/plan. The template contains reference to med student’s ROS and PFSH.
- Dictation – Physician dictates his/her own HPI, Exam and Assessment/Plan.
- Refer to the student's ROS and PFSH IF the students worksheet is sent to Edit/Sign and saved in CareWeb Documents as document type STUDENTWKST
- Dictate the ROS and PFSH IF you delete the student's worksheet from the Notifications Inbox
- If the Attending Physician sends the med student’s note to Edit/Sign, the note will appear in Medical Documents Viewer in CareWeb as a Med Student Worksheet auto-signed as student.
- If the Attending Physician clicks on Delete, the student’s note will not appear in the CareWeb Med Doc Viewer. A copy of the note will be saved but not viewable at this time.
If the House Officer completes the Physician’s note, the Teaching Physician must add the appropriate attestation of presence when signing as before.
Step-by-step instructions are now available..
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Is there training available?
Yes, please contact the Professional Fee Billing Reimbursement, Compliance and Education office at jeanaf@umich.edu to schedule education.***************************************************************
What do I need to do before the effective date of May 12?
The medical student scribe template has been removed from CareWeb and the new Medical Student Worksheets are now available for your use.
If you use a medical student scribe template, you must discontinue using it on May 12, 2008.
Physicians / Departments may customize the worksheets / templates with specialty-specific information.
- If you create custom templates, please send them to Rosemary Higgerson at rmusic@med.umich.edu for posting to the Approved Template section of Create Doc.
- If you determine the generic template meets your needs, you don’t need to do anything else for CareWeb.
- If you do not use either the generic template or a customized template, you must ensure that physicians in your department place their note above the medical student’s note in the CareWeb record.
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What if a non-physician provider (NPP) provides a billable service in conjunction with a medical student?
The guidelines for NPPs (e.g., PAs, NPs) have not changed. If the medical student starts a note using the Medical Student Worksheet, and the NPP provides a billable service, the NPP must document his/her findings and plan as before. The NPP may use the upper portion of the student template to document his/her findings and plan. If the Attending provides a portion of the face-to-face service, the shared visit rules apply.
Step-by-step instructions are now available.
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Does this policy apply to PA, NP or nursing students, or to other scribing situations?
No. The FGP is currently analyzing the utilization of scribes in other situations, including other students who may be serving as scribes. However, at this time, there have been no changes to those situations. Services provided and documented by House Officers should follow Teaching Physicians rules.
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Where can I find more information?
Information related to this policy is posted on the Reimbursement, Compliance, and Education website at http://www.med.umich.edu/rce/student
Step-by-step instructions are now available.
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Who should I contact with questions?
If you have any additional questions, please contact:
- Kristin Scarcella– Professional Billing Reimbursement Compliance & Education
- Dr. Charlie Koopman– Professional Billing Reimbursement, Compliance & Education
- Synthia Winnie– Health Information Management
- Rosanne Whitehouse - Health Information Management
- MCIT Helpdesk – or contact (734)936-8000 for the MCIT CareWeb Team
- Dr. Joe Fantone – Medical Education
- Dr. Cyril Grum – Medical Education
- Dr. Lisa Colletti - GME