News: CMS updates guidelines for using student documentation for E/M coding

CMS now allows teaching physicians to verify in the medical record any student documentation of E/M services, rather than re-documenting the work. The new update was released last week in Transmittal 3971.

Previously, CMS permitted students to document E/M services in the medical record, but the teaching physicians were required to re-document the student’s documentation for reporting purposes, Revenue Cycle Advisor reported. The new allowance will essentially raise student documentation to the level of a resident’s documentation, which has long only required a co-sign from the attending physician.

Just as is required with resident documentation, this update allows physicians to verify in the medical record all student documentation or findings, including history, physical, and/or medical decision making.

The teaching physician must personally perform or re-perform the physician exam and decision making activities of the E/M service being billed, according to Revenue Cycle Advisor, but the update saves them from the obligation to re-document the information.

This change is part of CMS’ broad goal to reduce the administrative burden on practitioners, CMS says.

Editor’s note: To read the story from Revenue Cycle Advisor, click here. To read the release from CMS regarding this change, click here. To read about CMS’ other efforts to reduce administrative burden, click here.