The Medicare and Medicaid EHR Incentive Programs does do not
prescribe additional requirements related to documentation in electronic health
records. Providers and practitioners are required to adhere to all
applicable laws, regulations, program instructions, policies and procedures
specific to EHRs. Providers are expected to adhere to established
policies, procedures, and legalities specific to the integrity of EHRs found in
existing requirements and such as the Medicare physician fee
schedule.
Regarding medical student documentation, we refer providers
to the Medicare Claims Processing Manual (Internet-Only Manual Pub. 100-04,
Chapter 12, Section 100.1.1.B), physician fee schedule. Medicare
physician fee schedule rules state which states that students may document
services in the medical record. However, the documentation of an E/M service by
a student that may be referred to by the teaching physician is limited to
documentation related to the review of systems and/or past family/social
history. The teaching physician may not refer to a student's documentation of
physical exam findings or medical decision making in his or her personal note.
If the medical student documents E/M services, the teaching physician must
verify and re-document the history of present illness as well as perform and
re-document the physical exam and medical decision making activities of the service.
(IOM Pub. 100-04, chapter 12, section 100.1.1B).
For additional guidance and information related to medical
documentation please refer to the Program Medicaid Integrity Documentation
Matters Toolkit, available on the CMS Website at https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/documentation-matters.html
and the Complying With Medical Record Documentation Requirements Fact Sheet
available at MLN Connects webpage: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/mln-publications-items/icn909160.html.
(FAQ19061)
