Premade Template Guidelines

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5
Location
Citrus Heights, CA
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0
I've got a provider that has built templates for specific insurances. While templates aren't a bad thing, the way these are built are greatly concerning.

The template looks like a complete document with prebuilt HPI, ROS, Exam, Assessments, and Procedures. Essentially, the visit looks complete enough without actually ever being completed by the provider that if a note is signed in error for whatever reason, it looks complete with all coding. Just maybe a missing E&M that may have been forgotten.

After discussing the possible complications and issues, I'm being asked for specific references to guidelines stating that it's not allowed. I'm getting kickback stating that if the provider changes it here and there that it's fine.

Is there any way someone can help direct me on references from CMS, AMA, or another reputable source that can help clarify the situation regarding pre-built templates?

Any guidance is greatly appreciated!
 

CatchTheWind

True Blue
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619
Location
Boca Raton, FL
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0
This is from First Coast Service Options (the MAC for Florida) at https://medicare.fcso.com/Publications_A/2006/138374.pdf : “Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same 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. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services."

Your MAC may address the issue in a similar manner.
 
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