Did you hear a collective sigh of relief on March 5, 2018? If so, it may have come from teaching physicians, who are the beneficiaries of change brought about by the Centers for Medicare & Medicaid Services (CMS) Documentation Requirement Simplification workgroup. The change? Documentation of an evaluation and management (E/M) service by a medical student can be used to support the teaching physician’s billing of the E/M service provided the documentation shows the teaching physician verified the history and personally performed the physical examination and medical decision-making (MDM).

As shown in the Table on page 8, the requirement that any contribution and participation of a student to the performance of a billable service (other than review of systems and past, family, social history) must be performed in the presence of a teaching physician or resident is unchanged. However, physicians no longer need to completely re-document the history of present...

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