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.