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What You Need To Know About CMS Change Request 10412

What You Need To Know About CMS Change Request 10412

Change Request (CR) 10412 revises the Medicare Claims Processing Manual to allow the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work. Make sure your billing staffs are aware of the changes.

What does this mean to you?

The Centers for Medicare & Medicaid Services (CMS) is revising the Medicare Claims Processing Manual, Chapter 12, Section 100.1.1, to update its policy on Evaluation and Management (E/M) documentation to allow the teaching physician to verify in the medical record any medical student’s documentation of components of E/M services, rather than re-documenting the work.

According to CMS Change Request 10412, students may document services they provide in the medical record. However, the teaching physician must verify 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.

Our recommended approach

We asked Lindsey Baldwin at CMS what TP documentation is required. Her response is below:

There is no additional sub-regulatory guidance at this time beyond what is stated in the revised manual guidance. You may want to reach out to your local Medicare Administrative Contractor (MAC) for additional guidance.

MedData recommends continuing with the CMS 2017 guidance (the medical student is only allowed to document the PFSH and ROS) until CMS issues further clarification on requirements.  

Initially, the potential benefit is that the provider is not required to re-document services already provided. However, combining the Medical Student, Resident, APP and Teaching Physician documentation, as well as defining who is to attest to what part of the documentation and what documentation from the TP is required for different levels of providers, is problematic. There are obvious risks, particularly medical/legal, when accepting a medical student’s documentation into your chart.

MedData will provide additional recommendations when CMS clarifies their position.


MedData Disclaimer – This document is provided for general informational purposes only and is not intended as legal advice. The providing of the information in this document is neither intended to establish an attorney-client relationship nor to expand the existing contractual relationship with MedData. MedData would recommend that you consult with your own internal legal resources before taking any action in reliance on this information.

Dr. Hallet Watz MD, MDA, FACEP

Dr. Hal Watz serves on the executive committee of MedData and holds the position of chief medical officer.

This Post Has 7 Comments
  1. Based on the above change, if a medical student documents an inpatient history, ongoing progress notes, and/or discharge summary, and if properly attested by the attending physician, can coders use those diagnoses to assign a DRG for the hospitalization?

  2. The medical student(MS) is not working as a scribe. The medical student is working as a medcal student. Prior to 3-5-18 they could not document more than ROS and PFSH which the TP had to review and agree with. Now the MS can document more the HPI, PE and MDM but the TP has to obtain their own HX, PE and MDM. The saving for the TP is in the documentation. They have to attest to the acdcuracy of the MS’s documentation.

    1. My question is regarding documentation by the medical student which the teaching physician attests as accurate after of course obtaining his/her own history, physical, and MDM. Since this is now acceptable to be used for E&M billing, can the document also now be used by coders to assign a DRG? I have reached out to our MAC but no response as of yet.

  3. I understand medical students and scribes can document progress-notes and ed records in the EHR. Though, is there a way for medical students to document on a teaching bases without that note being apart of the EHR?

    1. Medical students, on rotation, often document in the EHR as part of their training. In this scenario they are not acting as a scribe. All patients seen by a medical student must have their care supervised and be seen by the attending (teaching) physician, even if a resident is involved.

      According to MLN Matters, MM10412, updated June 2018, the teaching physician can verify in the medical record any student documentation of E/M components.

      The Centers for Medicare & Medicaid Services (CMS) is revising the Medicare Claims Processing Manual, Chapter 12, Section 100.1.1, to update policy on Evaluation and Management (E/M) documentation to allow the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work. 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 (more on this can be found here).

      We recommend having a process and policy to verify and support medical student documentation as it does become part of the permanent medical record and is subject to discovery.

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