New CMS guidelines eliminate requirement to re-document student notes

On February 2, the Centers for Medicare and Medicaid released a revised transmittal, Pub 100-04 Medicare Claims Processing Manual, that “allows the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than redocumenting the work.”

Previous guidance for claims processing from CMS prohibited teaching physicians from referring to student documentation of physical exam findings or decision-making. Many healthcare systems prohibited student access to electronic health records based on their interpretation of these guidelines.

“This change increases efficiency and allows students to be contributing members of care teams,” said Annie Rutter, MD, Chair of an interdisciplinary/interprofessional Precepting Expansion Initiative that approached CMS with a request for revised guidelines. “Medical decision making, of course, is always the responsibility of the physician.”

The Precepting Expansion Initiative, which is being led by the Society of Teachers of Family Medicine, is implementing several tactics to address the critical shortage of primary care clinical training sites. “Our goal,” said Rutter, “is to reduce administrative burdens for clinical preceptors and enhance learning. Students can play a valuable role in primary care practices, improving patient care and contributing to physicians’ lifelong learning and job satisfaction.”

Mary Theobald is a healthcare communications executive and the project director for the Precepting Expansion Initiative.

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