Policy change from CMS: Medical Student Documentation Allowed to Support Clinical Billing

CMS has updated the teaching physician requirements related to Medical Student documentation. Read a memo from Julie Byerley, MD, MPH, Vice Dean for Education, on the implications of the change.

Great news to share… In order to reduce administrative burden on providers, CMS has updated the teaching physician requirements related to Medical Student documentation.  CMS has removed the requirement that if the medical student documents E/M services, the teaching physician must verify and redocument the history of present illness as well as redocument the physical exam (PE) and medical decision making (MDM).  The change now states the teaching physician must verify all documentation or findings by the student and must personally perform (or re-perform) the PE and MDM, but may verify any student documentation rather than re-documenting. See changes in red below.

Special thanks goes to Dean Roper for his important individual role in advocating for this change.   Also special thank you to Beat Steiner, MD, MPH, Assistant Dean for Clinical Education and President Elect of the Society of Teachers of Family Medicine, who worked with national advocacy teams on this change, and also to Robin Davis Shuping, RN, MHA, CPC |HCS Director, Professional Compliance, UNC Health Care and her team who helped to advance this locally at UNC.   UNC Health Care has been a leader nationally in advocating for authentic clinical experiences that allow the presence of a medical student to add value to the clinical encounter.  This CMS change will allow students to add even more value by better supporting documentation of the clinical encounters they are involved in.  More details will soon be released about how this will be implemented in epic at UNC. 

 Full Policy Text:

100.1.1 - Evaluation and Management (E/M) Services

(Rev. 3971, Issued: 02- 02- 18, Effective: 01-01-18, Implementation: 03- 05-18)

B. E/M Service Documentation Provided By Students

Any contribution and participation of a student to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing.

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.

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Julie Story Byerley, MD, MPH

Vice Dean for Education, UNC SOM

Professor of Pediatrics

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