Major CMS Change Regarding Medical Student Documentation

SUMMARY:

…allow the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work. Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.

What New Provider Action is Needed?

• Previously, teaching physicians were required to re-document the medical student’s Evaluation and Management (E/M) documentation
• With this revision, the teaching physician can verify in the medical record any student documentation of components of E/M services

KEY POINTS:

• The CMS states that this change was “part of a broader goal to reduce administrative burden on practioners.”
• This change addresses concerns by medical education professionals and organizations that medical students entering residencies be familiar with documentation, particularly the use of electronic health records
  • The ACP had passed resolution 3-F15 in 2015, calling on

CMS to change the 2008 guidelines to allow teaching physicians to refer to a student’s documentation of the history and physical examination findings or medical decision making in his or her personal note for documentation of an E&M service

• Billing departments should be made aware of these new changes

Medicare Claims Processing Manual

Changes in bold italics

Chapter 12-100.1.1 – Evaluation and Management (E/M) Services

(Rev. 3971, Issued: 02- 02- 18, Effective: 01-01-18, Implementation: 03- 05-18)

B. E/M Service Documentation Provided By Students

Any contribution and participation of a student to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing.

Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.

Learn More – Primary Sources:

CMS Medical Learning Network: E/M Service Documentation Provided By Students (Manual Update)

CMS Medicare Claims Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners