Reader Questions: CMS Spells Out MD's Role in E/M

Why This Topic Matters

Understanding who may record portions of E/M documentation and how physician review is documented is important for compliance, audit readiness, and consistent medical record support. The article also highlights that related requirements may differ by state and by service setting.

Article Sections

1. Question

   Introduces a reader question about physician responsibility for parts of an E/M visit and whether Medicare addresses the issue directly.

2. Answer

   Summarizes CMS guidance on documentation of history elements and the roles of staff, patients, and physicians in the record.

3. Be careful:

   Highlights the need for physician review notation and caution around documentation practices used to support credit for history information.

4. Straight from the source:

   Quotes language from the 1995 and 1997 E/M documentation guidelines and references related documentation language for exam elements.

5. Watch out:

   Notes that state requirements may affect incident-to services and physician sign-off or plan-of-care expectations.