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CMS Revises Rules on Medical Student Documentation

February 9, 2018

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PRESS CONTACTS
Ivy Baer, Senior Director and Regulatory Counsel

The Centers for Medicare and Medicaid Services (CMS) Feb. 2 issued a revision to a Medicare manual that allows teaching physicians to use all student documentation for billable services provided that the teaching physician verifies the documentation. The teaching physician must either personally perform or re-perform the physical exam and medical decision making but does not need to re-document.

In the past, only the medical student’s documentation of Review of Systems and Past Family and Social History did not need to be re-documented by the teaching physician. CMS has not changed the requirement that any contribution of the student must be performed in the physical presence of the teaching physician or a resident. If the service is performed in the presence of a resident, then all teaching physician billing rules apply.

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