P4A153: Impact of Centers for Medicare and Medicaid Services Medical Student Note Policy Change on Physician Note Writing Practices

Background: In February 2018, the Centers for Medicare and Medicaid Services (CMS) released CR 10412, a provision that allows physicians to bill CMS for services using medical student documentation. In July 2018, our institution adopted policies to align with the updated CMS guidelines. With this change, physicians at our institution were able to addend a student note, which could then be used for billing. Since the CMS policy changes, little is known about the impact of incorporating student notes into the daily workflow of residents and faculty.

Methods: Daily progress notes as well as history and physicals (H&Ps) from a hospital medicine service at a freestanding children’s hospital were identified from January 2017 to March 2023 and divided among four cohorts for analysis (Figure 1). The length of time each provider spent editing the note, as recorded by the EMR, was used to evaluate differences between groups. A linear mixed effects model (LMM) with random effects for student and either resident or attending (depending on analysis) and a fixed effect for group was used to compare the length of time an attending (or resident) spent editing notes. Model adjusted means and standard errors were used for descriptive statistics. Analysis was done with SAS 9.4 and a p-value < 0.05 was considered statistically significant.

Results: Included in the analysis were 46,850 notes from 32 attending physicians, 346 residents, and 553 students. Data for mean length of time spent editing notes is presented in Table 1. We found no significant difference in the time an attending spent on resident, M3, and M4 notes (p=0.15) or on resident notes before and after July 2018 (p=0.72). Residents spent less time editing an M3 note than they did authoring their own notes (p < 0.0001). Attendings spent less time editing notes in the second half of the academic year for M4 notes (p=0.041) but not for M3 notes (p=0.27).

Conclusion: Our study demonstrates no additional time burden on the attending physician by incorporating student note writing into the clinical workflow. Additionally, residents spent less time on notes when editing an M3 note, which can be greatly beneficial to resident workflows. Note writing is a valuable opportunity for students and their ability to participate regularly in documentation is critical to their education, better preparing them for residency training. Further studies are warranted to better understand the quality of medical student documentation and its impact upon physician billing and coding practices.