Template Documentation Points to Ponder
CMS allows providers to use documentation templates, but the resulting note—whether paper or electronic—must be specific to the patient and the service rendered. To ensure compliant use of templates, consider these basic guidelines as provided by Wisconsin Physicians Service Insurance Corporation (WPS) Medicare:
- Either the ancillary staff or the patient may complete the review of systems (ROS) and the past family social history (PFSH) as part of the template, checklist, and/or electronic health record (EHR). The provider must notate his or her review of the information. Additions to the file or confirming notations substantiate the provider’s review.
- The provider may use an ROS or PFSH from a previous encounter. The provider must notate the date of the earlier ROS or PFSH and review all elements of the previous encounter notating any changes or elements not reviewed.
- The billing provider must perform the history of present illness (HPI). The ancillary staff cannot collect this information and enter it into the medical record with the provider only signing or acknowledging they read the notation.
- Documentation must clearly define the examination and findings to support the level of service submitted.
- A brief statement or notation of “negative” or “normal” is sufficient to document normal findings.
- The provider must document any specific and pertinent abnormal and relevant negative findings of the affected or symptomatic body area(s) or organ system(s). A notation of “abnormal” without elaboration is insufficient documentation.
- The provider must describe any abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ(s) systems.
- Forward a copy of abbreviations or “keys” used in the document if these are other than standard medical abbreviations.
- Signature requirements do not change with the use of templates, checklists, and/or EHRs. The documentation must show a legible identifier of the provider. You can find more information on the signature requirements in addition to attestation statements in the CMS Internet-only Manuals (IOM), publication 100-08, chapter 3, section 188.8.131.52.D.
- Providers should be wary of templates that have pre-printed information indicating certain “comprehensive” level services were performed. Documentation for each encounter must be specific to that encounter.
Peggy Stilley, CPC, CPMA, CPC-I, COBGC, ACS-OB, is director of Auditing Services, AAPC Physician Services (AAPCPS). She has more than 30 years of experience in the health care industry. She is a national speaker and has presented for The Coding Institute, Ingenix, and Medical Business Institute, as well as for AAPC’s national conferences, workshops, and webinars, and has published articles on coding, billing, and practice management. She has served as president and membership officer in her local chapter.