decisionhealth Newsletters, Part B News - 2012 Issue 12 (December)
CMS to auditors: Look for templates that lead to insufficient documentation
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Article Overview
This article covers CMS guidance on documentation templates used in paper and electronic medical records, with attention to how auditors evaluate notes for completeness and clinical specificity. It is aimed at coders, compliance staff, auditors, and providers who work with encounter documentation across specialties. The article discusses common template-related pitfalls, broader compliance considerations, and general approaches to improving documentation quality without limiting provider flexibility.
Why This Topic Matters
Documentation quality can affect claim support, audit outcomes, and repayment risk. Understanding CMS’s concerns about templates helps practices review note design, staff education, and documentation workflows.
Article Sections
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Documentation
Introduces the CMS documentation topic and the concern that certain note structures may not capture enough encounter-specific information.
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Rid notes of template risk
Summarizes practical considerations for reducing template-related documentation problems across paper and electronic notes.
What You Will Learn
- How CMS frames concerns about documentation templates
- What kinds of template features can affect note completeness
- General ways practices can structure paper and electronic documentation
- How education and workflow design can support better documentation quality
Who Should Read This
- Medical coders
- Compliance staff
- Auditors
- Physicians
- Practice managers
- Medical office staff
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