Department of Medicine, Stanford University School of Medicine, 300 Pasteur Dr. Stanford, Stanford, CA, 94305, USA.
J Gen Intern Med. 2019 Apr;34(4):634-635. doi: 10.1007/s11606-019-04853-7. Epub 2019 Feb 12.
The Centers for Medicare and Medicaid Services (CMS) recently revised their Medicare Claims Processing Manual with the addition of CR 10412, a provision that permits teaching providers to fully bill for medical student notes. This change will have significant implications on the documentation duties of teaching physicians and trainees. Potential benefits of this provision include reduced documentation burden on house officers, improved medical student empowerment, and the infusion of more original content into the electronic medical record. However, these benefits may be offset by shifting the burden of documentation onto medical students, which may compromise their time spent with patients and overall wellness. In this perspective, we review the changes that occurred with CR 10412 and their potential impact on documentation across the medical education spectrum.
医疗保险和医疗补助服务中心（CMS）最近修订了医疗保险理赔处理手册，增加了 CR 10412 条款，允许教学机构全额为医学生的笔记计费。这一变化将对教学医生和受训者的文件记录职责产生重大影响。这一条款的潜在好处包括减少住院医师的文件记录负担、增强医学生的能力以及将更多原创内容注入电子病历。然而，这些好处可能会因将文件记录的负担转移到医学生身上而被抵消，这可能会影响他们与患者相处的时间和整体健康状况。在这篇观点文章中，我们回顾了 CR 10412 带来的变化及其对整个医学教育领域文件记录的潜在影响。
