CMS Update: E/M Service Documentation Provided by Students

Beginning March 5, 2018 medical students are able to document their work in the patient record, including the patient history and physical exam portions of the evaluation and management service. The appropriate teaching physician must verify the information, and make any corrections, if needed, rather than re-documenting the work. The teaching physician must personally perform, or re-perform, the physical exam and medical decision-making portions of the E/M service being billed, but any student documentation of them may be verified and remain in the patient record. This is a big (and welcome) change for academic medical centers and their teaching physicians!