Must NP Preceptors Duplicate a Student's Documentation?

Carolyn Buppert, MSN, JD

Disclosures

August 17, 2018

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Question

A nurse practitioner (NP) functioning as an NP student's preceptor asked a question that could also apply to a certified nurse midwife (CNM) or physician assistant (PA) preceptor: "What part of the student's documentation am I required to repeat?"

Response from Carolyn Buppert, MSN, JD
Healthcare attorney

Before answering, we need to consider the three purposes of documentation:

  • Communicating with future providers;

  • Defending against a lawsuit for malpractice; and

  • Proving the clinician provided the service billed.

Medical record documentation tells future providers what the clinician found, what he/she did, what he/she taught the patient, and what the clinician recommended. If the student's documentation is satisfactory to communicate these elements, then the preceptor wouldn't need to repeat it or add to it for communication purposes. With respect to providing a defense for the preceptor or clinician, if sued, the questions to answer are:

  • Does the student's documentation show that the preceptor met the standard of care—that is, took the appropriate history, performed the appropriate physical exam, made the appropriate diagnosis, ordered the appropriate tests, and prescribed the appropriate therapies?

  • Does the student's documentation show that the preceptor sufficiently informed and educated the patient about the treatment plan and what the patient needed to do or not do? If the answer is yes, the preceptor wouldn't need to repeat or add to the student's documentation.

Fulfilling the third purpose of documentation is more complicated. Medicare and most other payers require that the credentialed provider under whose name the service is billed perform and document the required elements of the visit. The requirements for the various levels of visits are found in Current Procedural Terminology, published by the American Medical Association, and Medicare's Documentation Guidelines for Evaluation and Management. The preceptor, not the student, is the credentialed provider, so it is the preceptor who needs to meet the documentation requirements to support the bill. If billing Medicare, the preceptor will need to re-perform and re-document the history, exam, and medical decision-making. Medicare does not require that a credentialed provider redo the past, family, or social history or the review of systems. Medicare has held that past, family, and social history and review of systems can be taken and recorded by the patient, or any individual. Other payers usually follow Medicare's rules, but for a definitive answer from a commercial payer or Medicaid, contact the payer.

In February 2018, Medicare issued a statement that teaching physicians no longer needed to re-document the medical student's history, exam, and medical decision-making. The teaching physician now needs only to verify the student's work and document the verification.[1]

But does this apply to NPs and PAs as well? According to Medicare officials, the change applies only to teaching physicians. A CMS administrator clarified their position in May 2018 in response to queries from professional organizations. CMS responded that the change applies only to medical students and physician preceptors, but not to NP students, PA students, NPs, or PAs.[2]

Right now, Medicare has no rules specific to NPs and PAs on the issue of documentation by preceptors. Extending these changes to NP and PA students would require additional rulemaking. In my opinion, for the purposes of billing Medicare and probably for other payers, it is the preceptor who will need to document the history, exam, and medical decision-making. The preceptor need not repeat the student's documentation of past, family, and social history or review of systems.

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