AMA CPT® Assistant - 1998 Issue 1 (January)
Documentation Guidelines, No Use of Templates (Q&A) (January 1998)
January 1998 page 11a Coding Consultation Documentation Guidelines, No Use of Templates (Q&A) How does HCFA feel about templates for physicians to use when dictating exams? These would be physician prompts to comment upon the mandated elements of the exam, not actual verbiage that would "spit out" with the striking of a single key? AMA Comment HCFA is opposed to templates for physicians to use when dictating exams, because the minimum requirements of the Documentation Guidelines does not preclude adherence to other physician, institutional, and/or medical record documentation requirements. Documentation Guidelines, No Use of Templates (Q&A). CPT®...
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Article Overview
This short Q&A article addresses documentation guidance in the context of physician exam dictation and the use of templates. It is relevant to coders, compliance staff, and medical documentation professionals who need to understand the general policy discussion referenced by HCFA and AMA in relation to documentation requirements.
Why This Topic Matters
Documentation practices can affect coding accuracy, compliance review, and medical record completeness. This article helps readers identify the broader guidance environment surrounding exam documentation without delving into code-specific selection.
What You Will Learn
- The general documentation topic discussed in the Q&A
- How the article frames the discussion of templates in physician exam dictation
- The organizations referenced in the documentation guidance context
- The type of compliance and documentation issue being addressed
Who Should Read This
- Medical coders
- Coding auditors
- Compliance professionals
- Physicians
- Health information management staff
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