Medicare eases burden for E/M documentation involving medical students

If you teach medical students in your practice and involve them in your evaluation and management (E/M) encounters, your documentation burden for their work is getting easier.

Previously, Medicare said (in section 100.1.1.B of chapter 12 of the Medicare Claims Processing Manual) that students could document E/M services in the medical record. However, the teaching physician could refer to a student’s documentation only as it related to the review of systems or past family/social history. Medicare prohibited the teaching physician from referring to a student’s documentation of physical exam findings or medical decision-making in his or her personal note. Instead, Medicare required the teaching physician to verify and re-document the history of present illness as well as perform and re-document the physical exam and medical decision-making activities of the service, if the medical student documented E/M services.

CMS is now revising that section to allow a teaching physician to verify in the medical record student documentation of any components of E/M services. The changes go in effect on March 5, but they are effective for dates of service on or after Jan. 1 of this year. Medicare will still require the teaching physician to verify in the medical record all student documentation or findings, including history, physical exam, or medical decision-making. The teaching physician must also still personally perform (or re-perform) the physical exam and medical decision-making activities of the E/M service being billed although they may verify any student documentation of them in the medical record, rather than re-documenting this work.

It’s a small victory for administrative simplification in medical education but a victory nonetheless.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians