Did you know that Medicare allows teaching physicians to utilize medical student documentation to support billing evaluation and management (E&M) services?

The following criteria must be met when billing for services documented by medical students:

• Services must be E&M services (diagnostic and therapeutic services are prohibited).
• Medical students may document any and all components of the E&M service.
• E&M services must be performed in the physical presence of a teaching physician or resident.
• The teaching physician must personally perform (or re-perform) the physical exam and medical decision-making.
• The teaching physician must verify medical student documentation (residents are prohibited from verifying student documentation).
• Proof of teaching physician verification should be documented using an attestation. 

Example of a Suitable Attestation

“The medical student was personally supervised by me or my resident (resident’s name) during the patient examination. I personally performed a physical exam and the medical decision-making. I made appropriate changes to the documentation and the assessment and plan based on my verification, exam, and medical decision making.”

You can find the Medicare guidance in Chapter 12 Section 100.1.1 of the Medicare Claims Processing Manual: Medicare Claims Processing Manual (cms.gov)

Please contact the Office of Healthcare Compliance and Privacy for further guidance.