CMS (HCFA) Billing Guidelines

Current information is available on the CMS Web Page: Go to http://www.cms.hhs.gov/ and search key words “guidelines,” “teaching,” and “interns” for the Guidelines for Teaching Physicians, Interns, and Residents pdf. The following information is taken from the aforementioned pdf, page 3, at the above web site.

"Evaluation and Management Documentation Provided by Students--Any contribution and participation of a student to the performance of a billable service must be performed in the physical presence of a teaching physician or resident in a service that meets teaching physician billing requirements (other than the review of systems [ROS] and/or past, family, and/or social history [PFSH], which are taken as part of an E/M service and are not separately billable). Students may document services in the medical record; however, the teaching physician may only refer to the student’s documentation of an E/M service that is related to the ROS and/or PFSH. The teaching physician may not refer to a student’s documentation of physical examination findings or medical decision making in his or her personal note. If the student documents E/M services, the teaching physician must verify and redocument the history of present illness and perform and redocument the physical examination and medical decision making activities of the service."