Find-A-Code Focus Newsletter

CMS Releases Update to E&M Documentation Requirements in a Teaching Facility

February 21, 2018
On February 2, 2018, Centers for Medicare & Medicaid Services (CMS), issued new guidance regarding E&M Documentation in a teaching facility to be implemented by March 5, 2018. There was no change to any of the published rules regarding a student's ability to perform the Review of Systems (ROS) and Personal Family Social History (PFSH) provided they are collected in the presence of the teaching physician or a resident. The student is allowed to document in the medical record.
 
The change issued by CMS outlines that teaching physician now must verify all of the student's documentation within the medical record. The teaching physician must also PERSONALLY perform (or re-perform) the exam and the assessment and plan of the encounter. CMS states that the physician may verify the documentation of the student as opposed to having to re-document the exam and the assessment and plan.
 
To summarize the revisions:
  • The teaching physician must verify ALL student documentation
  • The teaching physician must PERSONALLY perform the exam and the assessment and plan
  • The teaching physician is NOT required to re-document the exam/assessment/plan, but merely verify the student's documentation of these findings. 

share
 

More Items in February 2018


To view more items select a month from our "Items by Month" list.

Or view documentation, coding and billing articles.

 

Poll

The ideal length of a webinar should be around:

News Items by Month
May 2020- 1
April 2020- 1
March 2020- 1
February 2020- 4
January 2020- 2
December 2019- 1
November 2019- 1
October 2019- 4
September 2019- 2
August 2019- 3
July 2019- 3
May 2019- 2
April 2019- 3
March 2019- 9
February 2019- 3
January 2019- 5
2018 - View
2017 - View
2016 - View
2015 - View
2014 - View
2013 - View
2012 - View
2011 - View
2010 - View
2009 - View
2008 - View
free demo
request yours today
pricing
for any budget
sign IN
welcome back!