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Cancel the rewrite! (By teaching M.D.s on E/M charts created by students, that is.)

Here’s a bit of news that should cheer up teaching physicians: Starting next month, they will not need to re-write E/M notes created by medical students.

According to CMS 100-04, Change Request 10412, the change comes courtesy of the Documentation Requirement Simplification workgroup and “allows the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work.” However, doctors will have to keep re-writing for a little longer. The new rule goes into effect March 5.

The update also adds medical decision-making to the portion of the visit that the student may perform.

To help staff understand what's changed, give them the current and revised language in IOM 100-04, Chapter 12, §100.1.1(B):


Students may document services in the medical record. However, the documentation of an E/M service by a student that 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 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 and redocument the history of present illness as well as perform and redocument the physical exam and medical decision-making activities of the service.

Effective March 5 (emphasis added by CMS in italics):

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.

Blog Tags: CMS, E/M services
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Reader Comments (1)
I am concerned that you left out any comment regard the paragraph preceding the section you quoted. In this paragraph CMS describes a requirement that the medical student can only perform service in the ‘presence of’ the resident or teaching physician. Does the resident and/or the teaching physician need include this in their attestation statement? “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.”


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