CMS OKs medical students' notes in patient records

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CMS updated the Medicare Claims Processing Manual to allow student documentation in patient records, beginning March 5.

The update revises how teaching physicians bill Medicare Administrative Contractors for services provided to Medicare beneficiaries. Under the update, a medical student may document evaluation and management services in a patient record, so long as the appropriate teaching physician verifies the information, according to a Feb. 5 agency notice.

In the past, teaching physicians were asked to re-document the student's work, including patient histories and physical exams.

"The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation … in the medical record, rather than re-documenting this work," the notice reads.

To access CMS's notice, click here.

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