APRN and PA students and medical record documentation

Question

We have students from a nurse practitioner program rotate through our practice. Can we use their notes the same way as medical student notes?

Answer

As of January 1, 2020, yes. The quotes below are excerpts from the 2020 Physician Fee Schedule Final Rule. Here’s the cliff notes:

• A physician, APRN or PA can review and verify, rather than re-document, information entered by any physician, APRN or PA student.

Need more detail? Read the long, medical record documentation article I wrote about the topic. Or, sign up for March’s webinar. In the meantime, here are a few excerpts from the rule.

We noted that this paragraph would specify that, when furnishing their professional services, the clinician may review and verify (sign/date) notes in a patient’s medical record made by other physicians, residents, nurses, students, or other members of the medical team, including notes documenting the practitioner’s presence and participation in the services, rather than fully re-documenting the information. We did not propose any limitations that would restrict a billing professional to only reviewing and verifying documentation in the medical record entered by health care team members practicing or training within their same specialty or discipline.

We believe that this type of limitation on our proposal would defeat our intended purpose to provide broad flexibility, establishing a generalized principle for medical record documentation for all professional services paid under the Medicare PFS in all settings. Therefore, we disagree with the commenters’ recommendation, and are not finalizing restrictions on the scope of medical record documentation entered by members of the medical team that can be reviewed and verified by the billing professional.

Additionally, our documentation proposal does not address any applicable billing or payment requirements for the work or services that others furnish in connection with the professional services that are billed by teaching physicians, other physicians, PAs or APRNs. Rather, our proposal is limited to addressing who is authorized, for purposes of the Medicare program, to review and verify documentation in the medical record entered by certain individuals, without having to re-document the information.