The Centers for Medicare and Medicaid Services (CMS) has issued revised requirements to auditors for reviewing pre- and post-payment claims when EHR templates are used. While CMS does not specifically prohibit or endorse the use of EHR templates, it has instructed auditors to take a closer look at claims involving the use of templates to make sure all services are properly documented, according to an article from the Center for Public Integrity.
HIM professionals should review the current instructions and whether their own organization’s system complies with the new rules. CMS discourages EHR templates with limited features such as check boxes, predefined answers, dropdown menus, or limited space for entering information.
CMS states that “progress notes created with limited space templates in the absence of other acceptable medical record entries do not constitute sufficient documentation of a face-to-face visit and medical examination.” Rather, the information provided through the template should be accompanied by additional acceptable records of the exam.
This revision follows other recent efforts that have been made to combat Medicare and Medicaid reimbursement fraud. A letter from Department of Health and Human Services Secretary Kathleen Sebelius in September warned against attempts to leverage EHRs for increased payments, while the Office of the Inspector General commenced investigation on meaningful use fraud in October.
The specifics of the revisions, which went into effect December 10, can be reviewed in Transmittal 438, Change Request 8033 on the CMS website.