On February 2, 2018, the Centers for Medicare & Medicaid Services (CMS) revised the documentation requirements associated with medical student entries in the medical record. Previously, when medical students entered notes in the medical record, CMS required teaching physicians to re-document certain entries. Review of systems (ROS) and past, family and/or social history (PFSH) were the only areas where re-documentation was not required. Under the new rules, which took effect January 1, 2018, teaching physicians are now able to verify student documentation of all components of Evaluation and Management (E/M) services in the medical record.
Effective January 1, 2018, Change Request (CR) 10412 revises the Medicare Claims Processing Manual Chapter 12, Section 100.1.1, to allow medical students to document services in the medical record as long as the teaching physician personally performs (or re-performs) the physical exam and medical decision making activities of the E/M service being billed and verifies all student documentation and findings in the medical record. If these conditions are satisfied, the teaching physician will not have to re-document the medical student's medical record entries.
This revision to documentation requirements does not change the requirement that any contribution and/or participation of a medical student to the performance of a billable service (aside from components of E/M services that are not separately billable such as ROS and PFSH) must be performed in the physical presence of a teaching physician or a resident (if the primary care exception applies).
Providers should be aware of the recent changes to documentation requirements pertaining to medical students and consider whether to change any internal documentation policies and guidelines. Dentons can answer any questions you may have about the recent Change Request, or the broader topic of teaching physician billing rules.