• Updated E/M Documentation Rules Good for Preceptors

    Interprofessional Initiative Aims to Support Primary Care Clerkships

    February 16, 2018 03:34 pm News Staff – Heeding a groundswell of calls from multiple stakeholders -- including members of the so-called family of family medicine -- CMS recently announced a change the agency is making to its Medicare Claims Processing Manual that will have a positive impact on family physicians who bill Medicare for evaluation and management (E/M) services while precepting medical students.   

    As has long been the case, students' participation in and contributions to the performance of a billable service must be done in the physical presence of a teaching physician or resident. That requirement will not change.

    What will change, however, is how those contributions may be documented in the medical record.

    Specifically, according to a Medicare Learning Network (MLN) article, this revision will now allow the teaching physician "to verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work."

    As explained in the article, the teaching physician still must personally perform -- or re-perform -- the patient's physical exam and the medical decision-making activities that went into the E/M services he or she is billing. But the revised documentation guidance promises to save preceptors time and hassle, and should help ease physicians' path to taking on a precepting role.

    • CMS recently changed the rules for medical student documentation of evaluation and management (E/M) services in a patient's medical record.
    • Physician preceptors can now verify in the medical record any student documentation of components of E/M services rather than re-document the work themselves.
    • The change will save time for teaching physicians, and the reduced burden could encourage more physicians to serve as preceptors.  

    The update became effective with services provided on and after Jan. 1, 2018, and will be implemented on March 5.

    Multi-stakeholder Advocacy

    It's important to note that this particular update to CMS' claims processing policy did not happen in a vacuum. Rather, it was coaxed along in large part by a plan developed by the Society of Teachers of Family Medicine (STFM) and other stakeholders, and implemented by multi-disciplinary, interprofessional tactic teams to address a critical shortage of community preceptors.

    That plan, in turn, is part and parcel of a larger endeavor championed by Family Medicine for America's Health: the Precepting Expansion Initiative.  

    In the face of a rapidly shrinking pool of quality clinical training sites willing to sponsor primary care clerkships, STFM convened a summit in August 2016 that drew a wide range of participants committed to finding solutions to address this threat. The end product of that summit was a Primary Care Preceptor Expansion Action Plan that outlines five specific tactics to decrease the percentage of primary care clerkship directors who report difficulty finding clinical preceptor sites and increase the percentage of students who complete clerkships at high-functioning sites.

    Importantly, the very first item on that list reads, "Work with CMS to revise student documentation guidelines."

    The remaining tactics are to

    • integrate interprofessional/interdisciplinary education into ambulatory primary care settings;
    • develop standardized onboarding processes for students and preceptors, and integrate students into the work of ambulatory primary care settings in useful and authentic ways;
    • develop educational collaboratives across departments, specialties, professions and institutions to improve administrative efficiencies; and
    • promote productivity incentive plans that include teaching, and develop a culture of teaching in clinical settings.

    In a background document used to support the requested change, the Tactic 1 team stated that CMS' guidance for claims processing had "inadvertently hampered medical education and increased the administrative and regulatory burden on the teaching physician."

    "The effect of this additional burden is that it has negative implications for physicians deciding whether to oversee students," said the tactic team.

    The backgrounder noted that although the CMS guidelines did not prohibit students from writing in the medical records, "many health care systems have prohibited student access based on their interpretation of these guidelines," resulting in suboptimal training for students.

    Specifically, drawbacks of limiting student use of electronic health records could include

    • impeding the development of medical student competencies necessary for clinical care,
    • interfering with the preceptor's ability to assess a student's progress and
    • increasing the risk that patient safety might be compromised when students transition to clinical care.

    "Students must experience and learn the role(s) they will assume as members of a clinical care team," the backgrounder stated.

    Members of the tactic team met with CMS officials in December 2017 to advocate the change and propose revised transmittal language, later submitting additional information, at the agency's request, about the amount of time the change would save preceptors.

    CMS issued the revised transmittal on Feb. 2.

    Apply for Pilot Program by Feb. 28

    In related news, STFM and the American Board of Family Medicine (ABFM) have issued a call for applications from academic units such as medical school departments of family medicine and family medicine residency programs to become sponsoring institutions in a Precepting Performance Improvement Pilot Program.  

    The program offers performance improvement credit for continuing certification (formerly Maintenance of Certification Part IV) to ABFM Diplomates who provide personal instruction, training and supervision to a medical student or resident -- and also participate in a teaching improvement activity.

    Interested parties need to act quickly because the deadline for applications is Feb. 28. Following completion of the pilot program, the ABFM intends to open the program up to all academic units/preceptors.

    AAFP Welcomes New E/M Documentation Guidance

    CMS' recent announcement that it would change requirements related to medical students' ability to document components of evaluation and management (E/M) services comes as good news to the AAFP, which has long advocated to improve and modernize the agency's E/M documentation guidelines to account for new models of team-based care.

    Specifically, the Academy has called for changes that would expand the ability of ancillary staff and others -- including medical students -- involved in a patient's care to document components of E/M services in the medical record.

    "In today's medical practice, information gathered and generated not only by ancillary staff members but also by care coordinators becomes part of the visit note and medical record," said the AAFP in a 2015 letter to the agency. "We believe that all the elements of team-based care that are part of the patient's office visit, if reviewed by and finalized by a physician or other qualified health care professional, should be considered part of the E/M service and supporting documentation."

    The Academy reiterated that request in an August 2017 comment letter to CMS on the agency's proposed 2018 Medicare physician fee schedule and, according to staff in the AAFP Government Relations Division, will continue to chip away at E/M documentation hassles.