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CMS E/M Service Documentation Provided by Students


New E/M Service Documentation Provided by Students requirements included in Transmittal 4068, published on May 31, 2018

Note that Transmittal 3971, dated February 2, 2018, was "rescinded and replaced by Transmittal 4068, dated, May 31, 2018, to correct typos to section number 100.1.1 on the Transmittal page and business requirement 10412.1, and part of the manual update under section 100.1.1. All other information remains the same."

What changed?
Previous language:
Students may document services in the medical record. However, the documentation of an E/M service by a student may be referred to by the teaching physician is limited to documentation related to the review of systems and/or past family/social history. The teaching physician may not refer to a student's documentation of the physical exam findings or medical decision making in his or her personal note. If the medical student documents E/M services, the teaching physician must verify the history as well as perform and redocument the physical exam and medical decision making activities of the service.

Current language:
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.

Why was there a change?
The previous language hindered student learning and caused an unnecessary paperwork burden on preceptors. An interprofessional, interdisciplinary team (medical, PA, and NP), developed through a Society of Teachers of Family Medicine (STFM)-led Preceptor Expansion Initiative, approached Centers for Medicare and Medicaid Services with a request to change the restrictions on the use of the student note so that teaching physicians could edit/amend/use the student note and not have to write an additional note to bill for the visit. CMS agreed that the previous language was burdensome and supported the request to change the requirements to allow use of the student note, as long as certain conditions are met by the teaching physician.

How do these CMS changes reduce the administrative burden on preceptors?
When student documentation is allowed for billing purposes, the unnecessary administrative burden of rewriting the entire note is removed. The implications for the preceptors' management of their clinical time are compelling.

  • In a survey of preceptors in January 2018, just under 92% indicated that allowing students to help more with documentation would save them administrative time after clinic. The bulk of respondents (48.3%) said they would save between 31-60 minutes per half-day session, and an additional 30% would save up to 30 minutes per half-day session.

Respondents reported that it would save them administrative time, enable them to spend more time teaching, allow them to consider precepting additional students, help them enjoy the practice of medicine more, and allow them to spend less time outside of patient care hours finishing their charts.

Does the teaching physician have to be in the patient's room at all times with the student?
The transmittal language has always stated: "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 which 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."

On May 8, 2018, CMS confirmed that there has been no change to the physical presence requirement. The only guidelines change is related to the ability to use the verified student note. There appears to be variability in how institutions comply with the physical presence requirement. In any scenario, the teaching physician must verify all student documentation in the medical record and personally re- perform the physical exam and medical decision making services used to support an E&M charge.

How could a teaching physician "verify" student documentation in the medical record?
STFM members have suggested these attestation statements:

  • I attest that I have reviewed the student note and that the components of the history of the present illness, the physical exam, and the assessment and plan documented were performed by me or were performed in my presence by the student and verified by me.
  • I attest that I was physically present with the student, verified all student documentation, and performed (or re-performed) the physical exam and medical decision making.

What if a resident is involved?
On May 8, 2018, CMS responded to our request for clarification regarding the role of residents within the context of students and teaching physicians with a comment that "they did not make any changes to the requirements or the relevant manual language."

The tactic team that made the original request to CMS has asked for additional guidance. Since the purpose of the teaching physician rule relates to how residents fit into the work of the teaching physician, it's important to have clarity on documentation guidelines when both residents and students are in a teaching setting.

Do these changes also apply to the inpatient setting?
Yes. CMS noted in its May 8 response that it did not make any changes to the rules on settings. It noted, "the manual defines ‘Teaching Setting' as any provider, hospital-based provider, or nonprovider setting in which Medicare payment for the services of residents is made by the A/B MAC (A) under the direct graduate medical education payment methodology or freestanding skilled nursing facility or home health agency in which such payments are made on a reasonable cost basis."

The transmittal changes the requirements for teaching physicians to allow them to use student notes for billing purposes without redocumentation. Is this limited to medical students, or can nurse practitioner and physician assistant students' documentation also be used without redocumentation?
Through an email received on May 8, 2018, a CMS administrator communicated that the change introduced on February 5 does not apply to nurse practitioner or physician assistant students. The members of the Preceptor Expansion Initiative disagree with the basis for the exclusion and will be responding to CMS with an argument in support of the inclusion of NP and PA students. This argument is based on CMS's own definition of a student as "an individual who participates in an accredited educational program (e.g., a medical school) that is not an approved GME program.

Last modified: Jan 22, 2019