E/M Documentation Can Be Provided by Students Again

E/M Documentation Can Be Provided by Students Again

Physicians won’t have to re-document medical students’ notes in evaluation and management (E/M) documentation any longer.

CR10412 revises the Medicare Claims Processing Manual to allow the teaching physician to verify in the medical record any student documentation of components of E/M services rather than having to re-document the work. It appears from the change request that some type of Teaching Physician such as the Resident Teaching Physician Attestation will be allowed to be used for notes documented by students. The implementation date of this CR is March 5, 2018.

Evaluation and Management – CEMC

A Change in Documentation

Currently, the teaching physician must re-document the work that the student documented. If the student sees the patient with the teaching physician, the student has been able to assume the role of a scribe. But the teaching physician has not been able to use an attestation to use the student’s E/M documentation. This is changing as of March 5, 2018.

This modification falls under the Medicare Claims Processing Manual internal only manual Publication 100-04, Chapter 12, Section 100.1.1 to update policy on E/M documentation to allow for teaching physician to verify in the medical record any student documentation of components of E/M services rather than re-documenting the work. The teaching physician must verify in the medical record all student documentation or findings, including history, physical exam, and medical decision making activities found in the E/M.

It is expected that CMS will come out with guidance on the wording for the student attestation.

Barbara Cobuzzi

Barbara Cobuzzi

Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is a consultant with CRN Healthcare Solutions in Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers.Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.
Barbara Cobuzzi

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Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is a consultant with CRN Healthcare Solutions in Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers. Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.

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