Medicare

Medical student documentation myth

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.

The myth

Teaching physicians are required to re-document medical student entries in the patient record.*

Debunking the myth

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.

Regulatory clarification

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, 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.

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.

Source: MLN Matters Number: MM10412; effective date: Jan. 1, 2018; implementation date: March 5, 2018

Summary of changes

This revision to Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, Section 100.1.1, B. E/M Documentation Provided by Students, allows the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work.

*The contents of the AMA’s debunking regulatory myths series are intended to convey general information only, based on guidance issued by applicable regulatory agencies, and not to provide legal advice or opinions. The contents of debunking regulatory myths should not be construed as, and should not be relied upon for, legal advice in any particular circumstance or fact situation. An attorney should be contacted for advice on specific legal issues.