CMS no longer requires physicians to redo medical student E/M documentation — 4 insights

CMS issued an update to its policy on evaluation and management documentation provided by students, allowing teaching physicians to verify student work rather than re-documenting it.

Here are four insights.

1. Students performing a billable service must do so with a teaching physician or resident who meets certain requirements present.

2. Students are permitted to document services in the medical record, but the teaching physician must verify all student documentation, including history, physical exam and medical decision making.

3. The physician is required to personally perform or re-perform the physical exam and medical decision making of the E/M service being billed.

4. The change was implemented March 5.

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