E/M Coding Alert - 2018 Issue 4
Documentation: Revise Your Medical Student E/M Documentation Policies, CMS Says
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Article Overview
This article reviews a CMS change affecting documentation practices for teaching physician and medical student evaluation and management services under Medicare. It summarizes the prior approach, the updated documentation framework, the role of the teaching physician, and the implementation timing. The piece is relevant to physicians, teaching physicians, coders, compliance staff, and medical education teams who manage E/M documentation policies and workflow.
Why This Topic Matters
The update may reduce redundant documentation burden in teaching settings while changing how organizations train staff and structure E/M documentation processes. Readers need to understand the scope of the CMS policy shift, the effective date, and where the guidance appears in CMS materials.
Article Sections
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Look at What's Changed
Introduces the CMS policy update and situates it within broader efforts to reduce documentation burden. It also points readers to the related CMS and MLN materials.
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No Changes to How Encounter Is Performed
Clarifies that the update addresses documentation practices rather than the way the patient encounter itself is conducted. It highlights the practical impact on workflow and training in teaching settings.
What You Will Learn
- What CMS changed in its approach to student documentation for E/M services
- How the update affects teaching physician documentation workflow
- What parts of the encounter process remain unchanged
- When the policy change became effective
- Where to find the related CMS guidance materials
Who Should Read This
- Physicians
- Teaching physicians
- Medical coders
- Compliance staff
- Medical education administrators
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