As part of Centers for Medicare & Medicaid Services (CMS) efforts to reduce mandatory and duplicative documentation of services in the medical record, several substantive changes have been made over the last two years. A discussion of the changes can be found in CMS’s 2020 Physician Fee Schedule Final Rule on pages 377–389 of this 2,475-page document. Many of the changes apply to physicians working in a teaching environment, but some are relevant to all physicians.

It is important to understand that CMS has widely broadened who can document the record, but not what needs to be documented. Changes include being able review and verify a student’s note for documentation and billing purposes. However, the record must still show the teaching physician’s presence and participation in the service. The definition of “student” has been expanded to include not only medical students but also physician assistant and nurse practitioner students. Documentation by nurses can now be used by physicians.

The new policies apply to all services including evaluation and management, procedures, and diagnostic tests. The minimum documentation requirement is to sign and date the documentation prepared by other members of the health care team. For more detailed guidance, please see the updated ACEP Reimbursement FAQ on Teaching Physicians at www.acep.org/administration/reimbursement/reimbursement-faqs/teaching-physician-guidelines-faq/.

Dr. Lemanski is associate professor of emergency medicine at UMass Medical School-Baystate, ACEP alternate advisor to the CPT editorial panel, and Chair of ACEP Reimbursement Committee Workgroup 4.