Documentation and Billing for Services Provided by Midwives Teaching Obstetrics and Gynecology Residents and Medical Students

Authors

  • Angela Wilson-Liverman CNM, MSN,

    Assistant Professor, Corresponding author
    1. Department of Obstetrics and Gynecology at the Vanderbilt University School of Medicine in Nashville, TN.
    Search for more papers by this author
  • Joan Slager CNM, CPC, DNP, FACNM,

    Director
    1. Nurse-Midwifery Services at Bronson Women's Service in Kalamazoo, MI.
    Search for more papers by this author
  • Deborah Wage CNM, FNP, MSN

    Division Director
    1. Midwifery and Advanced Practice Nursing in the Department of Obstetrics and Gynecology at the Vanderbilt University School of Medicine in Nashville, TN.
    Search for more papers by this author

Assistant Professor, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, B1100 Medical Center North, Nashville, TN 37232–2519. E-mail: angela.wilson-liverman@vanderbilt.edu

Abstract

Certified nurse-midwives are teaching obstetrics and gynecology residents and medical students in major academic institutions across the United States. In these instances, the ability to appropriately document services rendered to support a billable service is paramount. This article explains the difference in requirements for mid-wives' documentation when working with residents compared with documentation required of an attending obstetrician-gynecologist. It also reviews the teaching physician guidelines developed by the Centers for Medicare and Medicaid Services (CMS) as well as current evaluation and management documentation requirements. Several examples of documentation are provided, as are suggestions for enhancement and simplification of the guidelines to include midwives. An important point to remember is that the CMS rules do not prohibit a certified nurse-midwife from teaching a resident.

Ancillary