In the recently finalized calendar year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule, CMS streamlined certain documentation requirements for evaluation and management (E/M) services. Among the changes, effective January 1, 2019, CMS removed certain potentially duplicative documentation requirements for teaching physicians when medical residents or other clinical personnel already have noted the relevant information in the medical record.

As a general rule, Medicare regulations historically have required teaching physicians to (1) be present at the time a service is furnished, and (2) personally document their participation in the provision of E/M services. 42 C.F.R. § 415.172(b) (2018). An exception for low- and mid-level complexity E/M services furnished in outpatient departments of teaching hospitals (or other ambulatory care settings for which teaching hospitals are eligible to receive GME reimbursement) permits experienced medical residents to perform certain E/M services outside the direct presence of the teaching physician, but also has required—until now—the teaching physicians themselves to “document the extent of [his or her] participation in the review and direction of the services.” 42 C.F.R. § 415.174(a)(3)(v) (2018).

In the CY 2019 MPFS Final Rule, CMS has removed the requirement that documentation of the teaching physician’s participation in the E/M service to be entered personally by the teaching physician. Medicare regulations will be revised, effective January 1, 2019, to provide expressly that while such documentation still is required, the “extent of the teaching physician’s participation [in an E/M service furnished by a resident in the outpatient department of a teaching hospital] may be demonstrated by the notes in the medical records made by a physician, resident, or nurse.” 42 C.F.R. § 415.174(a)(6) (2019).

These regulatory changes are consistent with, and build upon, revisions earlier this year to the Medicare Claims Processing Manual, wherein CMS revised documentation rules to permit teaching physicians to verify, rather than having to re-document, medical record notations entered by medical students who assist in the performance of a billable E/M service.

Notably, too, this easing of the longstanding requirement that teaching physicians personally document participation in the performance of E/M services is just one of several E/M documentation and coding changes in the Final Rule. This CMS Fact Sheet provides a helpful summary. The GME @ Dentons team can answer your questions regarding these and other recent changes to Medicare documentation requirements and payment policies.