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Evaluation and Management (E/M) Documentation Provided by Students

Evaluation and Management (E/M) Documentation Provided by Students February 19, 2018

On February 2, 2018, CMS issued a significant update to the E/M documentation requirements when performed by a student.  Historically, providers have been required to re-document all documentation recorded by a student with the exception of a review of systems or past, family, and social history.

The new rule, which will be implemented March 5, 2018 now states, “Students may document services in the medical record.  However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making.  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.

We recommend providers review the CMS Transmittal in its entirety and consider revision of policies and procedures related to student documentation of E/M services, as appropriate, in light of this change. 

The Transmittal may be viewed at:

The accompanying MLN Matters article may be viewed at:

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