Wiki EMR Auditing

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sandyt

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Hi,
I am a CPC, CFPC and work in a Family Practice residency program. I audit the residents but it has just come to my attention that insurance auditors are auditing from the templates and not the note. I was under the impression that as long as it is on the note it counts as documentation, but it is being argued that is not so. It is what is clicked not free texted. Please help because if this is true I need to restructure my whole auditing process. I need to be clear because I am basically "teaching" these new docs. Do I audit straight from the note? Or straight from the templates? Or do I need to incorporate the two somehow? I have done a google search but I can't seem to come up with the answers I am looking for. Any suggestions, facts, or links will be greatly appreciated.
Thanks!
Sandy:confused:
 
does your template populate to the progress note? and where does the free texting populate to? If the are not already incorporated then how does it appear as a cohesive note?
 
It all populates on the note. That's why I am a little confused, if everything is on the note does it matter?

Sandy Thomas CPC, CFPC
 
If it is all on the note then how do you know the insurance auditors are looking only at the template? The OIG does not condone templet only documentation and has stated that there should be a way to allow the providers to customize the entires for each patient. Free texting is a way to do this. So what insurance auditor told you tey look only at the template? If it is all on the note together how could they avoid it and how do they know what is template and what is free texted?
 
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