Medical student documentation is the process of medical students documenting clinical services, including history, physical exam and/or medical decision making, in a patient’s electronic medical record. Historically, the teaching physician was required to re-document the medical student’s entries.
The Centers for Medicare and Medicaid (CMS) issued revised guidance on medical student documentation (PDF) on Feb. 2, 2018.
Teaching physicians are required to re-document medical student entries in the patient record.*
CMS documentation requirements changed in February 2018, and now allow teaching physicians to “verify” in the medical record any student documentation of components of E/M services, rather than re-documenting the work, as long as this is consistent with state and institutional policies.
New guidance was issued from the Centers for Medicare and Medicaid Services in 2018.
The Centers for Medicare & Medicaid Services (CMS) revised the Medicare Claims Processing Manual (PDF), chapter 12, section 100.1.1, to update policy on Evaluation and Management (E/M) documentation to allow the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work. Students may document services in the medical record.1
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.2
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1CMS Manual System: Pub 100-04 Medicare Claims Processing. Chapter 12, Section 100.1.
The Centers for Medicare & Medicaid Services, May 31, 2018
2E/M Service Documentation Provided By Students (Manual Update). MLN Matters.
The Centers for Medicare & Medicaid Services, June 1, 2018