Doctors Don't Need to Redocument Students' EHR Entries: CMS

Kerry Dooley Young

February 15, 2018

Federal officials will let medical students' entries into electronic health records stand for parts of Medicare claims, eliminating a need for teaching physicians to redocument much of their work.

The Centers for Medicare & Medicaid Services (CMS) on February 2 made changes to rules for billing for evaluation and management services. Teaching physicians still must personally perform or reperform physical exams and handle decision-making steps for an evaluation and management service, but they now can simply verify the students' documentation of them in the medical record.

CMS earlier required that teaching physicians both verify and redocument notes on the physical exam and medical decisions.

This new CMS approach on documenting claims will help prepare medical students to effectively use electronic health records, according to the American College of Physicians (ACP).

"Prior to the change, physicians were required to re-document most work performed by medical students — which is often very thorough and based on careful and supervised evaluation — rather than review, refer to, amend, and/or correct the student note," said Jack Ende, MD, ACP president, in a media statement.

The ACP said it worked with fellow medical groups, including the Alliance for Academic Internal Medicine, to push for this new policy. The changes regarding medical students' documentation have an effective date of January 1, 2018, but an implementation date of March 5, 2018.

CMS said this move is part of a broader effort to reduce bureaucratic burden on physicians, crediting it to its Documentation Requirement Simplification workgroup. In the same vein, CMS in October also launched a nationwide program to help providers of medical care avoid claims denials.

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