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AMA approves E&M documentation changes

The AMA CPT Editorial Panel has approved revised guidelines for new and established office or outpatient visit codes 99202-99215 that woul...

E/M Documentation for Teaching Docs Changes July 1, 2019


There is a change in Medicare policy forthcoming regarding evaluation and management (E/M) services documentation requirements for teaching physicians.

It is important to train teaching physicians, residents, and nurses who document E/M services of all changes to be implemented on July 1, 2019.

For purposes of payment, E/M services billed by teaching physicians require that the medical records must demonstrate,

1) That the teaching physician performed the service or was physically present during the key or critical portions of the service when performed by the resident;

2) The participation of the teaching physician in the management of the patient.

The patient medical record must document the extent of the teaching physician’s participation in the review and direction of the services furnished to each beneficiary. The extent of the teaching physician’s participation may be demonstrated by the notes made by the notes in the medical records made by physicians, residents, or nurses.

What Is CMS Telling Us?

The teaching physician’s participation may be documented by either the teaching physician, resident, or nurse as of July 1, 2019. This is a loosening of the current requirements, as we now may only use the teaching physician’s documentation of the participation. Documentation by the resident or the nurse of the teaching physician participation currently does not count in current documentation. But as of July 1, 2019, the resident’s and nurse’s documentation of the teaching physician’s participation will be counted.

Current attestations may not be used, as they do not include the “extent of the teaching physician’s participation in the review and direction of the services furnished to each beneficiary.” This means that current attestations will need to be extended to include free text that is specific to the beneficiary encounter, which will be different for each beneficiary.

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