Billing Compliance and Medical Student Documentation
The FGP Board recently approved a new policy on medical student documentation in patient records for billing purposes. May 12th, 2008 medical students will no longer be able to be used as scribes. The "Scribe" template in CareWeb has been removed and new templates are available to assist faculty and house officers in completing documentation required for billing when a medical student participates in the care of the patient.
The FGP is committed to a quality educational experience, and therefore medical students may continue to document their involvement in patient care in the medical record. However, to assure compliance with federal regulations and payer requirements, attending physicians and house officers may only refer to the medical student's documentation of the Review of Systems (ROS) and Past Medical, Family Medical and Social History (PMFSH) if this information is to be used for billing purposes.
-Daily care notes entered in the medical record by medical students should be edited as needed by the house officer and/or teaching physician.
-The house officer and/or teaching physician must personally obtain and document the History of Present Illness (HPI), Physical Exam (PE) and Medical Decision Making (MDM).
-When the house officer and/or teaching physician are both involved in a daily care encounter, the teaching physician will sign the document using the "With House Officer" attestation statement.
A flow chart illustrating the new CareWeb process is available.
CareWeb templates are available to accommodate these changes. Providers and departments should customize the templates with specialty information. Any template created should be sent to Krsitin Scarcella for approval and posting to the approved template section of create documents.
FGP Billing Compliance and Medical Student Documentation Policy
Frequently Asked Questions (FAQ)
If you have any questions or concerns or need more information about the new policy and the implementation plan, please contact RCE via email at Pro_Fee_Compliance@med.umich.edu or at 734-763-7232.
