A recent Legal Topics in Healthcare post described the CMS “Patients Over Paperwork” Initiative. One area of documentation impacted by this initiative lessens teaching-physician burden with student documentation that supports a patient’s E/M services.

In February 2018, CMS published CR10412, which allows a teaching physician to simply verify a student’s E/M visit notes rather than re-document components of the E/M services. This is a major change to the requirements prior to CR10412, where a physician was not allowed to refer to the student’s documentation of physical exam findings or medical decision making. In other words, the teaching physician was previously required to re-document E/M services already documented in the medical record by the student. This documentation included the history of present illness, physical exam, and medical decision making activities of the E/M service.

This change was effective February 2, 2018 in an effort to simplify the administrative burden on practitioners under CMS’ paperwork initiative. For more information, please refer to the official instruction, CR10412, issued to MACs regarding this change.

For more information on E/M documentation, please contact Linda at 781-272-8001.