Health Information Management

Tip: Use caution with E/M templates, checklists

APCs Insider, August 19, 2011

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When used appropriately, templates are good tools for any practice. Templates help promote the consistency of clinical care and documentation within a practice. They also help simplify the coding process and encourage appropriate code assignment.

CMS currently allows providers to use exam templates and checklists, but they must do so with caution. 

When used incorrectly, templates can affect a provider’s E/M level assignment. When using templates or checklists, providers should remember to document specific abnormal and relevant findings of an exam and affected or symptomatic body area(s) or organ system(s).

Providers also should describe abnormal and unexpected findings of any asymptomatic body area(s) or organ system(s). Providers can document normal findings with a brief statement or notation indicating “negative” or “normal.” For example, if a provider checks a box next to or circles auscultation of lungs and indicates “normal,” it means the provider listened to the lungs and heard nothing abnormal; this is acceptable documentation.

Documenting on an exam template, checklist, or dictated documentation that any organ system or body area is “abnormal” and receiving credit for this in an exam is unacceptable. For example, only checking a box or dictating auscultation of lungs as abnormal but not elaborating about what is abnormal for that system or body area is insufficient.

This tip was adapted from Auditing Evaluation and Management Services, A Step-By-Step Guide to Accurate Coding, Reimbursement, and Compliance, Second Edition. For more information or to order a copy of the book, visit HCPro’s Healthcare Marketplace.



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