CMS now allows medical student documentation for E/M billing

On February 2, 2018, the Centers for Medicare & Medicaid Services (CMS) issued an update to the Medicare Claims Processing Manual, stating that all medical student documentation can be used for evaluation and management (E/M) billing. Previously, medical students could document in the medical record, but teaching physicians were only allowed to rely on medical student documentation about the patient’s review of systems and past family and social history, not physical exam findings or medical decision making.

With this change, CMS now allows teaching hospitals to bill for E/M services based in part on a medical student’s documentation, as long as the teaching physician personally performs (or re-performs) the physical exam and medical decision making activities of the E/M service and verifies the medical student's documentation.  

This is a welcome change to teaching hospitals, as it frees the attending physician from re-documenting the patient encounter; however, it is important that teaching physicians carefully review (and edit, as necessary) the medical student documentation and consider the medical student’s skill and competency level in doing so. 

Hospitals may need to revisit the functionality of their electronic medical record (EMR) system, since many EMRs provide separate tabs for medical student notes rather than having the medical student documentation appear in the patient’s medical record. 

This change is effective January 1, 2018. 

Bricker & Eckler attorneys routinely advise hospitals regarding the multitude of compliance and security issues associated with health information management and EMRs. For assistance, contact the author or any member of our health care team.