E/M coding from templates


Meridian, ID
Best answers
I am struggling with E/M coding from a template. Does anyone know where I could get information or some kind of guidelines. I am uncomfortable with coding from the template when nothing is expounded on in each ROS and exam and it says the same thing for every single patient. I really could use some help!!! PLEASE!!

A few thoughts

In order to better help you I would need a little more information. When you say a "template" do you mean something like a check-off list? If so, that is common for the ROS - so long as the physician says something to refer to that list. Also isn't that uncommon to see that for an exam if there are items that are checked off after the physician does that - but I do agree that if there is NOTHING else and only this "template" that it would be a concern.

Also, if you have an EHR, then there could be further problems if this "template" has the look of each patient's information being copied and pasted elsewhere.

In any case, probably the best bet would be to bring this to the attention of who you report to (supervisor, director, physician, etc.)

Hope this helps.
The template has boxes that the providers can check, but under each ROS, and exam under organ systems, they each have a standard statement that comes up everytime that box is checked. For example: NECK: "Neck is supple, without JVD, adenopathy, murmur, burit or thyromeglay." That comes up everytime, how does a coder know if it was really done if the provider doesn't put "reviewed" or "within normal limits, or something to individualize it from patient to patient? I have brought this concern to managers. I just thought if I could find some kind of guidelines or something I could take to them and to educate myself would be helpful.

Thanks, Jeanne
here's what palmetto has to say on cloned notes:

Palmetto GBA Home
Jurisdiction 11 Part B

When documentation is worded exactly like*previous entries, the documentation is referred to as cloned documentation.

Whether the cloned documentation is handwritten, the result of pre-printed template, or use or Electronic Health Records, cloning of documentation will be considered misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.

It would not be expected that every patient had the same exact problem, symptoms, and required the exact same treatment. Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information for each unique patient.

Documentation exactly the same from patient to patient is considered cloned and often occurs when services have a specific set of limited or select criteria. Cloned documentation lacks the patient specific information necessary to support services rendered to each individual patient.


last updated on 12/06/2011
Your template sounds like EXAM not ROS

The example you cite sounds to me like an exam and NOT ROS. ROS is what the patient would report as any problems or issues. Also "NECK" is NOT one of the systems in the ROS.

So, whoever created this template for your physicians has made some serious errors.

Hope that helps.

F Tessa Bartels, CPC, CEMC