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.