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News & Press: General Announcement

CMS Reduces Burden for E/M Service Documentation

Monday, May 14, 2018   (0 Comments)
Posted by: David Walls
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CMS has updated their rules regarding E/M services that may be documented by medical students. The rule clarifies that medical students may document services directly into the Electronic Medical Record so long as the teaching physician verifies all documentation or findings.


This means all preceptors can take advantage of this teaching opportunity with students while reducing the need for the physician's time in entering data in their EHR. If you would like more information, or would like to become a preceptor, please contact Katie Fisher, DO, Director of Clinical Education at COMP-Northwest



Underlined text represents the changes CMS has made, which went into effect March, 2018


Any contribution and participation of a student to the performance of a billable service (other than the review of systems and/or past family/social history that are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing.
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.



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