CMS releases update to E/M service documentation provided by students

CMS released Transmittal 3971 on February 2 describing a revision to the Medicare Claims Processing Manual, Chapter 12, Section 100.1.1, B., “E/M Documentation Provided by Students.” This update, effective retroactively to January 1, 2018, allows teaching physicians to verify in the medical record any student documentation of E/M services, rather than re-documenting the work.

Previously, Section 100.1.1, B. of the Medicare Claims Processing Manual permitted students to document E/M services in the medical record. However, teaching physicians were required to re-document the medical student’s documentation.

The update allows physicians to 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 does not have to re-document the medical student’s findings.

According to CMS, this change is part of a broader goal to reduce the administrative burden on practitioners. Billing staff should be made aware of these changes to ensure that claims are being processed appropriately.

Additional information on this update can be found here.