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Templates are a useful tool for documenting the evaluation and management service, but remember, they can also make it very easy to document a higher level of service than provided.
Templates are a useful tool for documenting the evaluation and management (E&M) service, but remember, they can also make it very easy to document a higher level of service than provided. As long as your templates are consistent with the medically necessary service for your patient’s presenting problem, and not just force feeding extra components for a higher level of E&M service, they are working for your practice.
Payers and auditors worry on a regular basis that templates are contributing to “level creep,” the systematic increase in E&M levels supported by documentation through the use of either paper or EHR templates. From a systems point of view, templates are the correct tool to prompt the clinician, giving them the clues they need to document various history components, exam bullets, and medical decision making elements.
However, if the results these templates generate are not consistent with the true nature of the presenting problem (NPP), they can become instead an inaccurate tool for providing and documenting a higher level of service for your patients. This is not how your practice should operate as it may give your payers and/or auditors a dim view of your use of templates. Keep in mind that as the clinician you are ultimately responsible for limiting how extensively templates are used, the level of E&M service documented, and the degree of E&M service provided.
Where do you start when using templates? The extensiveness of your patient’s history and its contribution to the complexity and nature of the presenting problem will determine how much of an exam is needed. So, using a template to gather and document a comprehensive history is good medical care, as long as the physician conducts an exam that is dictated by the NPP. If the problem is straightforward, the exam should be problem focused or expanded problem focused at most, so even with a template, no more than this limited exam is required.
Letting the NPP dictate the level of service will guard against level creep, where the template is leading the physician to provide more services than those that are medically necessary. The medical decision making component will then flow from the appropriate exam and history. By using this methodology, even with the use of templates, the physician will not over document or provide more services than necessary. So remember, when using templates - or just evaluating how much work you are going to be doing - keep in mind the patient’s NPP and current history. If you do that, the medical necessity should become clear, prompting you to provide no more or no less than the patient’s problem requires.
Barbara J. Cobuzzi, MBA, CPC,is president of CRN Healthcare Solutions in Tinton Falls, N.J., a healthcare consulting firm. Cobuzzi is also a senior coder and auditor for The Coding Network and a past member of the American Academy of Professional Coders (AAPC) National Advisory Board and Executive Board. She has served as an expert witness on both civil and criminal fraud cases, and has written for many key publications in the medical coding and reimbursement industry.