E/M Weekly Tip: Documentation Provided by Students

The Centers for Medicare & Medicaid Services (CMS) has revised the Medicare Claims Processing Manual, Chapter 12, Section 100.1.1, to update policy on Evaluation and Management (E/M) documentation to 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.

Reference: MLN Matters article 10412 (PDF, 184 KB) for E/M Service Documentation Provided by Students.