CMS publishes new guidance on verifying E/M documentation by medical students

CMS recently released new documentation guidance on medical review of E/M services performed by medical students. A medical student may document E/M services if the physician performs or re-performs the exam and then verifies the student’s documentation.

In MM10627, released July 13, CMS instructs MACs to consider the verification requirement met if the physician signs and dates the medical student’s entry in the record.

MM10627 is a follow-up and clarification to a change request released in February that revised documentation guidelines to allow medical students to document services if the teaching physician personally performs the physical exam, medical decision-making, and verifies all student documentation. Prior to the February change, the teaching physician was required to re-document the medical student’s notes rather than simply verifying them.

Organizations should ensure their billing staff, teaching physicians, and medical students are aware of the change. If necessary, internal documentation policies and guidelines should be updated.