Preceptor Handbook

Important Information for Physicians Teaching Medical Students

In December of 1997, Dr. Rick Kellerman and I met with Dr. Satya-Murti of Blue Cross Blue Shield of Kansas. On the agenda was a discussion about how teaching medical students affects documentation and billing issues for the teaching physician. After a cordial discussion, Dr. Kellerman wrote up and exchanged documents with Dr. Sataya-Murti; finally reaching an agreement on recommendations for physicians who teach medical students. KAFP encourages you to teach medical students. Our university cannot hope to accomplish all the instruction that must take place in educating medical students without your help. We hope this document will help you by illuminating some accepted documentation and billing practices for physicians who teach medical students.

-Carolyn Gaughan, CAE

 

Recommendations for Physicians Teaching Medical Students

Medical student's services are not recognized by HCFA for reimbursement purposes.

Physicians may teach medical students. Part of the legitimate education of medical students is obtaining essential aspects of the medical history, performing a physical examination, developing an assessment, proposing a plan and participating in practice management systems including documentation in the medical record. All aspects of the patient's care for which the teaching physician wishes to bill are the responsibility of the teaching physician.

The physician may refer to the documentation made by the medical student in the medical record. The teaching physician should document the key elements of the patient's care for which he/she wishes to bill. The teaching physician's documentation should be specific to the scenario. The documentation should be in the "active voice," should highlight key elements of the history and examination directly performed by the teaching physician and emphasize that the clinical decision-making is under the purview of the physician.

For example, the teaching physician may document: "I repeated the patient's history and exam. The pain is resolved. The abdominal exam is without tenderness or mass. Blood pressure is well-controlled and I prescribed maintenance antihypertensive. RTO 3 months.' Another example: "I was present during the history and physical. The tiredness is improving. I agree with continuing observation." Another example: 'I was present to verify the shortness of breath, rales and ankle edema. Diagnosis: CHF. Treatment: Increase Lasix dosage." Another example: "I obtained a history similar to the medical student. In addition, I elicited a family history of sudden cardiac death. My examination also showed no heart murmur or irregularity."

"Active voice" means that it should be clear that the teaching physician was responsible for the patient's care. For example, dictate, "I do not think that this patient is in CHF" instead of 'It was decided that the patient was in CHF."

Documenting "the patient was seen and examined" will not suffice. A generic attestation or simple signature will not suffice.

The medical student may indicate in his/her note that the teaching physician was present and that key portions of the history and physical examination were repeated by the teaching physician. For example, "Dr. Docent interviewed the patient and repeated the key portion of the exam. We discussed the assessment and plan." Another example: "Dr. Docent verified my history and findings regarding the presence of ankle edema."

Teaching physicians may find it beneficial to have the medical student write their notes in the chart immediately after seeing the patient. The teaching physician may then review the note at the time of the visit and write in specific comments.

Some teaching physicians allow the medical student to dictate the office note without writing in the chart. The transcribed note usually returns to the teaching physician in 24 to 72 hours. If relying on a medical student's transcribed note, the teaching physician must be sure to write-in their specific comments when the note returns from transcription. Alternatively, the teaching physician may dictate or write-in their own note at the time of the visit.

The teaching physician may wish to "side-bar" or write in the margins of the student's notes to more specifically indicate the key elements of the history and exam that the teaching physician personally performed. Teaching physicians should clearly indicate that they were ultimately responsible for the assessment and plan. Using a "rubber stamp" or "macro' (inserting a standardized statement into the documentation) to help standardize the teaching physician documentation for each encounter contradicts the recommendation to be "scenario specific." Scenario-specific means that each patient encounter is unique.

The physician is paid for what the physician does... not what the medical student documents.

9212 and 99213 exams should be relatively easily documented by the teaching physician with the suggestions noted above. 99214 and 99215 exams should be documented in much more detail by the teaching physician.

14 JFP Fall 1998