A policy change by the Centers for Medicare and Medicaid Services (CMS) will make documenting evaluation and management (E/M) services more efficient for physicians who work with medical students. According to the policy change highlighted in MLN Matters Number: MM10412, beginning March 5, 2018, teaching physicians can now verify any student documentation of the E/M service rather than re-documenting the work.
That does not mean that physicians don’t have to do at least some of the work being documented, though. According to the new policy, “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.”
As for the documentation of the history (including the review of systems and the past, family, and social history), however, physicians can rely on the students’ work and simply verify the documentation, as in the past.
The old policy requiring physicians to re-perform and re-document their findings was implemented during the Obama Administration. In her Healthcare Dive article about the change, Les Masterson says that the requirements stemmed from “issues concerning students not providing enough information from examinations.” The unintended result of the policy, though, was that students were excluded from the documentation process.
This policy change continues the work of the Department of Health and Human Resources (HHS) under the Trump administration to “review regulations that affect the provision of care and the doctor-patient relationship, consulting with provider groups to determine what is raising the cost of care, lowering the quality of care, burdening their practices, or interfering with their relationships with their patients.” In 2017 alone, that review resulted in the Trump administration withdrawing 70 of the previous administration’s regulatory actions.
For more information about the policy, review MLN Matters Number: MM10412.
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