CMS Announces Changes to
Physician Documentation Requirements
December 6, 2002 - The Centers for Medicare and Medicaid
Services (CMS) Nov. 22 published changes
to the Carrier Manual Instructions (CMI), Section 15016, Supervising
Physicians in Teaching Settings (CR #2290). The revisions
were effective on the date they were issued.
CMS has been examining regulatory burden on physicians and
attempting to provide relief when feasible. Over the past
year, the Agency has worked with AAMC through the Group on
Faculty Practice Steering Committee to identify burdensome
aspects of the supervising physician requirements that could
be addressed through revisions to the CMI rather than through
changes in the regulation. While the teaching physician regulation
that was effective on July 1, 1996, remains unchanged, the
revised CMI makes important positive changes in the documentation
requirements.
The revised CMI should significantly reduce the documentation
burden on teaching physicians for E/M services when a resident
also is involved in the care of a patient. The revised language
makes it clear that for E/M services, teaching physicians
need not repeat documentation already provided by a resident.
It is important to note that with very limited exceptions,
a teaching physician still must write a personal note and,
unless the service is provided under the Primary Care Exception,
must be present for the "key portion" of the service.
Further, the revisions clarify other issues, including the
use of documentation by students, and updates regulatory references.
Each institution should carefully review the instructions.
Information:
Denise Dodero, Associate Vice President
AAMC Health Care Affairs
ddodero@aamc.org
(202) 828-0493
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