By now, we all know and live by the documentation guidelines outlined in the Medicare Supplier Manual, Chapter 3: "the patient's medical record must contain suf...

Using Templates for Medical Documentation 2021 | O&P Reimbursement

Using Templates for Medical Documentation

By now, we all know and live by the documentation guidelines outlined in the Medicare Supplier Manual, Chapter 3: "the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type of items ordered."

But how many of us take the easy route and use checklists or templates? Be aware that, according to CMS guidelines: templates do not qualify as adequate Medicare documentation and are subject to claim denials.

The Program Integrity Manual, 3.2.1.1, Progress Notes and Forms provides further information:

"Some templates provide limited options and/or space for the collection of information such as by using "check boxes," predefined answers, limited space to enter information, etc. CMS discourages the use of such templates. Claim review experience shows that that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met."