[co-author: Chelsea Sousa - Legal Intern]*

On February 2, 2018, the Centers for Medicare & Medicaid Services (CMS) released Transmittal 3971 (Change Request 10412), which revises a section of the Medicare Claims Processing Manual (Manual), that provides guidance regarding billing for Evaluation and Management (E/M) services involving students.  According to CMS, the Change Request is part of a broader goal to reduce the administrative burden on practitioners.

Prior to this change, Section 100.1.1(B) of Chapter 12 of the Manual stated that while a student involved in E/M services “may document services in the medical record,” a teaching physician may not refer to the student’s documentation of physical exam findings or medical decision making in the teaching physician’s personal note. Moreover, if a medical student documented E/M findings, the Manual provided that the teaching physician must verify and re-document the history of present illness, as well as perform and re-document the physical exam and medical decision making activities of the E/M service. As a result, in order to comply with the prior version of the Manual, teaching physicians had to perform documentation in the medical record of certain E/M services involving students that may have been duplicative of the documentation by students in the same medical record of the same services.

Under Transmittal 3971, the Manual does not contain a requirement that teaching physicians  re-document a student’s documentation of an E/M service, but instead provides that the physician must verify the student’s documentation. To be compliant with the Manual, the teaching physician still 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 in the patient’s official medical record instead of re-doing a student’s entries. In connection with this change, the Manual now provides that teaching physicians are obligated to “verify” in the medical record all student documentation or findings, and no longer contains a restriction on which types of E/M documentation a teaching physician could “refer” to in the teaching physician’s own note.  This change is effective January 1, 2018, but will not be implemented by CMS until March 5, 2018.

*This post was co-authored by Chelsea Sousa, legal intern at Robinson+Cole. Chelsea is not yet admitted to practice law.

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