decisionhealth Newsletters, Part B News - 2008 Issue 9 (September)
Don't let templates trump medical necessity on claims
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Article Overview
This article explains the risks of relying too heavily on electronic templates and automated EMR features when documenting patient encounters. It focuses on how documentation habits can affect evaluation and management coding, medical necessity, and audit exposure, and it is aimed at physicians, coders, auditors, and practice managers using EMR systems.
Why This Topic Matters
Overly templated documentation can create records that appear inflated, repetitive, or insufficiently individualized, which may draw payer scrutiny. Understanding the documentation risks helps clinical and coding teams support medically necessary services and reduce compliance concerns.
What You Will Learn
- How EMR templates can influence documentation patterns
- Why medical necessity remains central to evaluation and management documentation
- What risks arise from overly repetitive or automated charting
- How providers and coding staff can review template-driven documentation for relevance
- Why automated code selection functions may create compliance concerns
Who Should Read This
- Physicians
- Certified professional coders
- Medical auditors
- Practice managers
- Compliance staff
- Consultants
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