Medicare Revises E/M Service Documentation Provided by Students

On February 2, 2018, CMS issued Transmittal 3971 revising Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, Section 100.1.1, B, that allows the teaching physician to verify in the medical record any student documentation of components of evaluation and management (E/M) services, rather than redocumenting the work. The policy change applies to all students who teaching physicians supervise, including advance practice professionals. The revised policy reads as follows:

E/M Service Documentation Provided By Students

Any contribution and participation of a student to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing.

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.

Teaching physicians cannot simply co-sign the medical student's notes; that is not enough for billing. The teaching physician has a responsibility to read and edit the student's notes and obtain clarification from the student if needed. Teaching physicians along with the teaching hospitals should consider the level of skill and competency that their medical students need in order to accomplish the essential elements of the E/M service.

Although the policy change is specific to E/M services, it does not address documentation of procedures performed by students. A future MLN Matters from CMS may address the expectations of medical student skill and competency as well as documentation of procedures performed by students.