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Billing Documentation and Medical Student Involvement June Update. Reimbursement, Compliance and Education 734-763-7232 pro_fee_compliance@med.umich.edu http://www.med.umich.edu/u/compliance/billing/student/. Policy adopted by the FGP on Dec. 13, 2007 Effective May 12, 2008.
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Billing Documentation and Medical Student InvolvementJune Update Reimbursement, Compliance and Education 734-763-7232 pro_fee_compliance@med.umich.edu http://www.med.umich.edu/u/compliance/billing/student/
Policy adopted by the FGP on Dec. 13, 2007Effective May 12, 2008 • Updates and reminders based on feedback from providers, students and coders: • Template Format • Document Type & Signer • Faculty Attestation of Presence • Physician Documentation of Billable Service
Template FormatSeparate Physician & Student Notes The physician and student sections of the note must be clearly separated by a starred-dotted line and headings, such as: • ATTENDING or HOUSE OFFICER’S NOTE: The following note was documented by the House Officer/Attending. • MEDICAL STUDENT’S WORKSHEET: The following note was documented by the medical student.
Physician Note Heading Dotted Line Student Note Heading
Document Type & Signer If a note contains physician and student documentation, the Doc Type should be changed to the appropriate Doc Type(e.g. Admit H&P), and the signer is the Faculty.
Document Type & Signer If a note contains only medical student documentation, the Doc Type should remain MEDSTUDENTWKST, and the signer is Med School Ed (signer 98989)
Attestation Of Presence If the House Officer documents the physician note, the Faculty must still add the “With House Officer” attestation of presence when e-signing. Click on the dropdown menu labeled “Add Teaching Physician Statement.” Save & sign. The password protected attestation appears at the end of the note Password Protected Attestation Dropdown Menu
Physician Must Perform & Document the Billable Service • The physician’s note must contain the History of Present Illness, Physical Exam and Assessment & Plan to support the level of care. • All physician documentation must appear in the physician section of the note. • If the student’s documentation remains a part of the medical record, only their ROS and PFSH may be referenced and used for billing.
