CMS Rules for Medical Students: Documentation of E/M Services with a Teaching Physician

CMS has several provisions for medical students documenting E/M Services with a Teaching Physician. Below is a side-by-side comparison of the older vs. most recent provisions.

Older: Medicare Claims Processing Manual (MCM), Transmittal 2303 (updated 9/14/11) 

  1. As early as 2002 (and perhaps before then), CMS (then HCFA) stated that E/M services by medical students alone were not billable and would be reimbursed. See Med Student Advisory pdf.
  2. CMS reiterated in Sept. 2011 that a teaching physician (TP) must verify and re-document the history of the present illness (HPI), physical exam and medical decision making (MDM), if the student documents the E/M service. CMS Transmittal 2303.
  3. Procedures could not be performed and documented by a medical student, and then attested to by the TP for the procedure to be billable to Medicare. Students could participate in a billable procedure if the physician personally supervised the procedure, directed the student and the physician documented the procedure.

Newer: MCM Transmittal 3971, Issued 2/2/18 and became effective 3/5/18

  1. In the new CMS Transmittal 3971, CMS is changing its decades long policy re: student and TP documentation for E/M services.Please note that to date there is NO CHANGE in CMS’ policy regarding billable procedures (see 3. Below)
  2. Under the new CMS E/M policies, the TP must perform (or re-perform) the exam and MDM for the E/M service being billed, “…but may verify any student documentation of them in the medical record, rather than re-documenting this work.” (emphasis added)
  3. CMS stated that the effective date were dates of service 1/1/18, and implementation by the Medicare MACs was 3/5/18.

Meaning, Significance and Implications

  • Statements in the EHR that verify or attest to the medical student’s physical exam and medical decision making (MDM) appear to be permitted for the E/M services to be reimbursed by Medicare, although the transmittal is clear that the teaching physician must personally perform the physical exam and MDM.
  • Medicaid and Tricare may or may not follow these particular Medicare changes so payor specific research should be completed prior to implementation.
  • Commercial health plans do not generally have teaching physician policies as they are not reimbursing the hospitals for the graduate medical education of the students as is the case with Medicare (hospitals include the costs of medical education on their cost reports and certain aspects of that cost are reimbursed under Medicare Part A).