Part B Insider - 2018 Issue 4
Documentation: CMS Rethinks Its Policy on Students' E/M Documentation
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Article Overview
This article explains a CMS policy update affecting student participation in evaluation and management documentation in teaching environments, especially in emergency department settings. It is relevant to physicians, coders, compliance staff, and documentation educators who need to understand how the revised guidance affects recordkeeping, attestation, and workflow. The article also references CMS implementation guidance and the effective date for the change.
Why This Topic Matters
The update can affect documentation workflow, teaching physician attestation practices, EHR processes, and training for student and physician documentation in Medicare-covered settings.
Article Sections
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Get to Know What Changed - And What Didn't
Summarizes the CMS policy background and distinguishes the revised portions from the portions that remain unchanged. It also references related CMS guidance and commentary on the practical impact of the update.
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No Changes to How Encounter Is Performed
Explains that the update affects documentation rather than the clinical encounter itself. The section discusses broader implications for workflow and administrative burden.
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Put A Plan in Place for Your ED
Outlines operational considerations for emergency department implementation, including record identification, education, templates, and attestation preparation. It also notes the stated effective date and source materials.
What You Will Learn
- The scope of the CMS policy update for student participation in evaluation and management documentation
- How the change affects documentation workflow in teaching settings
- What operational areas may need review before implementing the updated guidance
- Which CMS reference materials are associated with the policy update
Who Should Read This
- Emergency department physicians
- Teaching physicians
- Medical coders
- Compliance professionals
- Hospital documentation staff
- Clinical documentation educators
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