Medical record templates have been in and out of the news quite frequently today. All medical record templates for one are not the created equally. Which templates are the “so called troublemakers”? We may see some additional complexities develop here since this seems to be an area where the discussion has lead to capturing bigger dollars when billing.
Is there really fraud? In order to be reimbursed for lengthy types of visits and procedures, some of the codes require that certain elements of a patient visit or consultation need to be addressed with the patient. The most common question arises as to when there’s a template that covers all of the items, with the required text. If this same template is used over and over without detailing any specific patient information, then yes it looks a little suspicious. Doctors are supposed to “use their own words” to a degree in “how they see” the patient and recommendations for treatment, follow up and so forth.
We have probably all read at this point about seeing a medical record entry that is several pages long and would indicate that a physician spent a lot of time with the patient, and then later the patient says he/she was in and out of the room in 30 seconds. That can happen but in essence I don’t think we find the majority of doctors practicing this way; however pressure from a hospital with using such templates has also been up for discussion, especially where integrated system will take the note, code it and bill.
As this moves forward, defining “what kind of a template” is used will certainly remain a topic of discussion and research to address this. CMS contractors will now begin auditing claims and sending back denials if they are suspected to fall into some of the new areas to be watched, so be on alert. CMS will be looking for suspected templates that are “cookie cutter” in nature and again having an integrated function to billing. It might be a good time to review and see what type of templates are in the EHR being used. As this begins I’m sure there will be a lot of questions and the complexity discussion of “templates” has just begun to establish some type of guidelines.
One EMR system, Praxis seems to have a handle on templates and recently was voted the #1 as preferred by doctors by the American Academy of Family Practice Physicians.
“Praxis® Electronic Medical Records (EMR-EHR) is template-free. Templates are rigid and slow charting down. Instead Praxis uses an innovative artificial intelligence technology called Concept Processing. The Concept Processor acts as a second medical brain mirroring the mind of each physician by recalling elements from past cases that are similar to the case being seen. This enables instant documentation in a provider’s own words, allowing individuality and creativity as opposed to restrictive data fields within template software. The more a physician uses Praxis EMR, the faster and more powerful it becomes.”
Is it perhaps time that other medical record vendors take a look and see what Praxis has been using for years as the system is “template free”. Perhaps Praxis was ahead of their time?