tci E/M Coding Alert - 2018 Issue 4

You Be the Coder: Know How This New Rule Changes Documentation Requirements

Question: Our providers complain about having to re-document the elements of E/M services performed in the hospital, even though their medical students have already documented them. Is there a way around this? California Subscriber Answer: Yes, fortunately there is now a way around at least part of the documentation requirements. Background:  CMS has long allowed students to document services in the medical record, but up until now, CMS policy has dictated that teaching physicians can only refer to the students' documentation for the review of systems (ROS) and/or past family/social history (PFSH). The student's documentation of physical exam...

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