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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.

Pub 100-04 Medicare Claims Processing Manual

September 15, 2016 ACP/IMEAB letter