Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.Now, if I had a note documented by a medical student with an attestation that the supervising physician had personally performed the services and verified what is in the medical student note, I would code any diagnoses documented in the assessment. There must be an attestation from the physician, not just a co-signature. This update is in the Medicare Claims Processing Manual Chapter 12 Section 100.1.1.
CMS eases guidelines on medical student documentation
To help reduce the burden of documentation on physicians, the Centers for Medicare and Medicaid Services (CMS) released new guidelines expanding the information medical students can document in the EMR and eliminating the need for teaching physicians to re-document the information.
What's more, medical student documentation can now be counted toward Evaluation and Management (E/M) billing. Thus, if you, as a teaching physician, are supervising medical students or any advance practice professionals who are documenting a patient exam, medical decision making and other components of a patient encounter, the E/M services can be billed to Medicare.Please see link to MLN dated March, 2018