Medicare Program Integrity Manual (Pub. 100-08), Ch. 6 § 6.8.1
Medical Review of E/M Documentation Provided by Student
6.8.1 – Medical Review of E/M Documentation Provided by Student
(Rev.808; Issued: 07-13-18; Effective: 08-14-18; Implementation: 08-14-18)
The Medicare Claims Processing Manual, Chapter 12, Section 100.1.1 (B) states 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. If the teaching physician chooses to rely on the medical student documentation and
chooses not to re-document the E/M service, contractors shall consider this requirement
met if the teaching physician signs and dates the medical student’s entry in the medical
record.