E&M documentation provided by students

As of March 5, 2018, the Center for Medicare and Medicaid Services (CMS) is allowing documentation from students to be considered part of the documentation for Evaluation & Management (E&M) services. The teaching physician must still document; they cannot only attest to the student documentation. To quote CMS, “The teaching physician must personally perform (or re-perform) the physical examination and the medical decision making activities of the E/M service being billed, but may verify any other student documentation of them in the medical record, rather than re-documentation of the work”. 

All student documentation must also be performed in the presence of the teaching physician or the physical presence of a resident to meet the requirements for teaching physician billing.