CMS Revises Policy on Student Documentation of E&M Services

The Centers for Medicare and Medicaid Services (CMS) is revising its policy on student documentation of evaluation and management (E&M) services provided to Medicare Part B beneficiaries.

Effective March 1, 2018, teaching physicians will be allowed to verify student documentation of E&M services in the medical record instead of re-documenting the work. CMS says it is making this change as part of its “Patients Over Paperwork” initiative to reduce burdensome regulations and streamline requirements.

Here are two key points to keep in mind concerning the revised policy:

  1. Students may document services in the medical record. However, the teaching physician must then verify in the medical record all student documentation or findings, including history, physical exam, and/or medical decision making.
  2. 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 he/she may verify them in the medical record rather than re-documenting the work.

For more details on this change, read CMS’ MLN Matters article here. To sign up for CMS’ “Patients over Paperwork” monthly newsletters, submit your email information here.

Pennsylvania Medical Society (PAMED) members with questions can also contact our Knowledge Center at 855-PAMED4U (855-726-3348) or KnowledgeCenter@pamedsoc.org.  

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