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Medical Student Documentation

New Guidelines from CMS on E/M Service Documentation Provided by Students

February 2, 2018: The Centers for Medicare and Medicaid (CMS) has released a revised transmittal, Pub 100-04 Medicare Claims Processing Manual, which “allows the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than redocumenting the work.” The revised guideline reads:

“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.”

The change has an implementation date of March 5, 2018.


Added June 2018: University of Chicago CCRC Student Documentation Guidelines 2018 (PDF)

Added June 2018: The Ohio State University E/M Service Documentation Provided By Students for Billing: FAQs (PDF)

Added June 2018: FAQs: New E/M Service Documentation Provided by Students requirements included in Transmittal 3971, published on Feb 2, 2018  (PDF)

Pub 100-04 Medicare Claims Processing Manual

September 15, 2016 ACP/IMEAB letter 

From Academic Internal Medicine Week 2018: New CMS Guidelines for Medical Student Documentation: Next Steps and Collaborations

Compliance Issues for which CAFM, AAMC and AAPA are seeking confirmation

AAMC: To-Do List for Implementing the CMS 2018 Manual Change Regarding the Use of Student Documentation by the Teaching Physician for Billing Purposes

Disclaimer: there has been no peer review conducted with submitted resources; AAIM reserves the right to reject submissions.