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

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.”

Revised guideline, with an implementation date of March 5 (changes highlighted in red):

“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.

Read the full revision document

Share This to Mobilize Preceptors

Help us address the critical shortage of clinical training sites by sharing the transmittal and the need for clinical training sites with preceptors, practice managers, compliance officers, and health systems leaders. Communicate that this change will greatly reduce the administrative burden of precepting. Students play a valuable role in primary care practices, improving patient care and contributing to the teaching physician’s lifelong learning and job satisfaction.

How Did This Change Come About?

In spring of 2017, the Tactic 1 team of the interprofessional, interdisciplinary Precepting Expansion Initiative was charged with working with CMS to revise student documentation guidelines that limited the student documentation role for billing purposes to review of systems and/or past family/social history and prohibit teaching physicians from referring to a student’s documentation of other parts of the history, physical exam findings, or decision-making.

The team and others invested in the outcome created a one-page request that was vetted by several organizations. Members of the team then met with CMS in December 2017, providing arguments in favor of the change and proposing revised transmittal language. CMS requested data to quantify the amount of time this change would save in a preceptor's clinical visit. The tactic team created a survey, which received 1,900 responses in 11 days, and sent the data to CMS on January 24. CMS released the revised transmittal on February 2.

Copyright 2018 by Society of Teachers of Family Medicine