The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.
Practical Tips for Concise and Compliant Coding
The attainment of concise and compliant documentation continues to evolve with the use of templates and forms. The Centers for Medicare and Medicaid Services (CMS) does not prohibit or encourage the use of a specific template for inclusion in medical records. CMS is concerned with the collection of information in the patient record that captures sufficient detailed clinical information demonstrating that coverage and coding requirements are met. The use of templates with “check boxes” and pre-defined answers is discouraged. Templates should be designed and used with compliance issues in mind. Patients who complete a history form need to sign and date it, as does the physician reviewing the document. The signature verification step does not change if the document is scanned as part of the electronic medical record. There must be “verification” by the provider that he or she reviewed the information for its inclusion in the medical record.