College of Medicine Office of Compliance, Gainesville, Florida
COMPLIANCE TIP

KEEP YOUR TRANSCRIPTION ACCESS NUMBER CONFIDENTIAL.

Keep your number protected and confidential.  Do not allow anyone to dictate using your number.

LIMITATIONS ON MEDCIAL STUDENT DICTATION:

The general standard for documentation for the College of Medicine is the Medicare standard.  Under the Medicare rules "a medical student is never considered a resident."

This means, in order to support a bill,  Medicare requires:

For Evaluation and Management Services

The medical student may complete and document the Review of Systems (ROS) and the Past, Family and Social History (PFSH) - which are segments of the history component of an Evaluation and Management (E&M) (CPT 99XXX) service.

The teaching physician may use the medical student's documentation for ROS and PSFH ONLY to support a billable service - provided the teaching physician personally documents in the teaching physician's own note that he/she has reviewed the medical student's documentation.

The teaching physician must personally perform/obtain and document the History of Present Illness (HPI) (portion of the HISTORY), the PHYSICAL EXAM, and MEDICAL DECISION MAKING components of the E&M service.

For Procedures

A medical student's contribution to the provision of a service may be billable if performed in the presence of the teaching physician (or in combination with a resident and teaching physician following the Teaching Physician Billing rules for residents and fellows.)  THE TEACHING PHYSICIAN MUST BE PRESENT FOR THE ENTIRE PROCEDURE AND THE TEACHING PHYSICIAN MUST PERSONALLY DOCUMENT THE PROCEDURE PERFORMED AND MUST PERSONALLY DOCUMENT THE TEACHING PHYSICIAN PRESENCE FOR THE ENTIRE PROCEDURE.

If you have any questions about this tip, or another compliance concern,
the Office of Compliance for the College of Medicine is here for you.
Please call (352) 265-8359 or e-mail Nina Tarnuzzer at nwt@ufl.edu.

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Webmaster<ahagan@dean.med.ufl.edu>College of Medicine, Office of Compliance  This page created September 18, 2002.  Maintenanced 02/13/06 Please read our disclaimer and permitted use statement.