decisionhealth Newsletters, Coder Pink Sheets - 2002 Issue 12 (December)
E/M template
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Article Overview
This article discusses how gastroenterology practices can build and refine evaluation and management template forms. It focuses on broad documentation concepts, such as aligning the form with medical necessity, accommodating physician workflow, supporting multiple service levels, and making the record easier to review and audit. The piece is aimed at physicians, coders, and practice staff who develop or use E/M documentation tools.
Why This Topic Matters
E/M templates can influence documentation quality, compliance, and how clearly a service level is supported. Understanding the article’s themes can help practices create forms that better match physician workflow and review expectations without overemphasizing documentation volume.
Article Sections
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Let MDM drive code selection and form the basis of your E/M template
This section discusses how medical decision-making and medical necessity influence evaluation and management documentation approaches. It also covers broad concerns about over-documentation, template design philosophy, and the role of professional guidance in template creation.
What You Will Learn
- How E/M templates are framed for gastroenterology documentation workflows
- Why medical necessity is presented as central to selecting an evaluation and management level
- What general features make a template more usable for physicians and easier to audit
- How template design can support documentation across different service levels
- Why practices may revise template drafts after implementation
Who Should Read This
- Gastroenterologists
- Medical coders
- Coding auditors
- Practice managers
- Revenue cycle staff
- Clinical documentation improvement staff
Codes Discussed
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Quick, Current, Complete - www.findacode.com