CMS Issues Guidance to Scrutinize Inadequate EMR Template Use
On Dec. 10, CMS issued Transmittal 438, subsequently updated in Transmittal 455 on March 15, 2013, that requires Review Contractors to target the inappropriate use of EMR template shortcuts. The transmittal states that CMS “does not prohibit the use of templates to facilitate record keeping”, nor does it “approve of or endorse any particular templates”.
The transmittal goes on to specify that it discourages templates with limited options, limited space, predefined answers, and checklists. The transmittal states, “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.”
Although this memorandum appears to initially target hospitals, physicians, and entities who quality for meaningful use incentives, it does identify licensed/certified medical professionals (LCMP’s). Care Plan Oversight and face-to-face encounter documentation of home health patients is an area that intersects with medical necessity and determination of payment as referenced in the memorandum and the related Medicare Program Integrity Manual.
The transmittal states that there are financial implications of inappropriate use of EMR template shortcuts, “The physician/LCMP (Licensed/Certified Medical Professional) should be aware that inadequate medical record documentation can lead to a financial liability for the Beneficiary and/or Supplier, should the reviewer determine that a claim is not supported.”
In response to a specific element of the transmittal related to “discouraging the use of template shortcuts with limitations”:
The design of the HomeSolutions.NET EMR and associated Flex Point of Care clinical documentation tools supports open ended data collection and documentation capabilities while also providing the data-driven reporting benefits of structured data elements when possible. It is consistent in the design philosophy of HomeSolutions to avoid “pre-populating” or “cloning” when documenting a patient encounter. This is balanced with securely providing clinicians with the ability to reference historical patient information for extended decision support, and to identify items such as changes in condition, wound progress, deviations and exceptions from the care plan or schedule, and overall progress towards patient-specific goals.
When HomeSolutions does employ validated lists or structured fields, it also allows for those to be appended when applicable to support dynamic documentation that will not be limited if the clinician determines the need to expand assessment or intervention notes.
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