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Auto Text

N

nklunk86

Contributor
Messages
15
Location
Paoli, IN
Does anyone have any strong resources on why providers should not be using the same auto text on all patients for billing. Here are a couple of examples I'm dealing with:
For obesity dx codes they use the same blurb about AMA recommends x amount of time exercising and about eating more veggies and fruits. There is noting specific to the patient.
Also on the tobacco counseling it's the same blurb about the risk of smoking but nothing specific to the patient for a plan on quitting.

Thanks!
 
https://www.cms.gov/medicare/medicaid-coordination/states/dcoumentation-matters-toolkit (see multiple links in here)

https://www.wpsgha.com/guides-resources/view/complete-and-timely-documentation-of-medicare-services (snip below)

Electronic Documentation​

When using electronic medical records to document, consider the following:

  • Can we identify what makes each encounter or service unique?
    • Indicate the review of copied information.
  • Can we identify the pages are one record?
  • Does each page indicate the patient’s identifying information?
  • Are required signatures included in the medical record?

 
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