Electronic Documentation Template Compliance with Ongoing Releases of Official Coding Guidelines

Electronic Documentation Template Compliance with Ongoing Releases of Official Coding Guidelines

By Lolita M. Jones, MSHS, RHIA, CCS

A template is an electronic health record (EHR) documentation tool utilized for the collection, presentation, and organization of clinical data elements; the template may also contain prompts designed to trigger the provider to specify required or missing documentation.1 Electronic documentation templates (EDTs) are often used by clinicians for diagnostic and therapeutic services that have limited technical variability from patient to patient, and whose documentation is therefore more suitable for standardization and automation.

EDTs are often used for the following procedures, which are frequently performed in the outpatient setting:

  • Cardiac catheterizations
  • Cataract extractions with intraocular lens placement
  • Colonoscopies
  • Electrophysiologic studies (EPS)
  • Esophagogastroduodenoscopies (EGDs)
  • Spinal nerve blocks (e.g., epidural, facet joint, transforaminal)
  • Spinal nerve destructions (e.g., cryotherapy, radiofrequency)

Many healthcare organizations (HCOs) have a formal committee and process, such as an Electronic Health Record (EHR) Documentation Governance Workgroup, that is charged with overseeing the development and maintenance of EDTs. A minimum annual EDT evaluation process, is recommended by AHIMA.2 As a result, it is not uncommon for an EHR Documentation Governance Workgroups to annually evaluate their EDTs based on the October 1st  ICD-10-CM/PCS diagnosis/procedure and the January 1st CPT procedure code additions, revisions, and deletions.

Unfortunately, many EHR Documentation Governance Workgroups do not perform ongoing EDT evaluations for compliance with new or revised official coding guidelines that are published throughout the year. Official ICD-10-CM and ICD-10-PCS coding guidelines are published each quarter in the American Hospital Association’s (AHA) Coding Clinic for ICD-10-CM/PCS. Official CPT and HCPCS Level II coding guidelines are published each quarter in the AHA’s Coding Clinic for HCPCS, and official CPT coding guidelines are also published monthly in the American Medical Association’s (AMA) CPT Assistant newsletter. Note:  Individual HCOs may also receive specific official guidance when they submit coding questions to the AHA and AMA.

When official coding guidelines have an impact on the standardized content of an HCO’s EDTs, and the EDTs are not revised as appropriate, the number of physician queries may increase because the coding specialists can no longer rely on the EDT content when trying to assign accurate, complete, and comprehensive codes. Two examples are provided below.

Endoscopic Mucosal Resection

EDTs are commonly used for colonoscopies and EGDs, and endoscopic mucosal resection (EMR) can be performed via a colonoscopy or EGD.

According to the AMA, CPT coding for EMR procedures requires the performance of ALL of these components: (1) a submucosal injection to the lift the lesion; (2) demarcation of the lesion, often by creating a pseudopolyp out of tissue; and (3) endoscopic snare resection.3

Many coding specialists are unable to assign an EMR CPT code, because the EDT lists “endoscopic mucosal resection performed” in the body of the template, but one or more of the three required components is missing, often the lesion demarcation is missing. A coding specialist will either:

  • Send a query to the physician asking for additional information that may support the assignment of an EMR CPT code; or
  • Follow the AMA’s directive to down-code the case using two codes–one for the submucosal injection and another for the snare resection procedure.4
Paravertebral Facet Joint Thermal Energy Denervation

EDTs are also commonly used for spinal nerve destructions (performed for pain management).

According to the AMA, low-grade thermal energy is defined as the application of heat that is less than 80 degrees Celsius, and when low-grade thermal energy is used to perform paravertebral facet joint denervation, an unlisted nervous system procedure code 64999 must be assigned (CPT codes 64633 – 64636 can be reported when temperatures higher than 80 degrees are used).5

Many coding specialists are unable to code from paravertebral facet joint thermal energy denervation EDTs, because the body of the template does not include the temperature of the heat that was applied. A coding specialist will either:

  • Send a query to the physician asking for additional information that may support the assignment of a specific CPT code; or
  • Down-code the case and assign the unlisted CPT code 64999.

One can easily see that EDTs that are not compliant with official coding guidelines may increase the number of physician queries, and reduce the quality of the data in the EHR, coding, and billing databases.

HIM Leadership and Ongoing EDT Monitoring

HIM participation on the EHR Documentation Governance Workgroup is the key to timely and successful ongoing EDT evaluation and revisions (as needed) when new or revised official coding guidelines are published. In the Practice Brief titled “Electronic Documentation Templates Support ICD-10-CM/PCS Implementation (2015 update),” AHIMA recommends:

  • HIM involvement/collaboration in EDT development and maintenance
  • EDT design to capture information needed for accurate reporting of the clinical encounter
  • Ongoing review of EHR templates and prompts
  • Proper EDT monitoring to support their use.6

Inpatient/outpatient senior coding specialists and coding education coordinators are examples of HIM professionals who could participate on the EHR Documentation Governance Workgroup, and take the lead in the ongoing EDT evaluation process by:

  • Compiling and storing blank copies of all active EDTs in the Workgroup’s shared electronic folder on the HCO’s intranet
  • Reviewing official coding guidelines as soon as they are released/published and any EDT(s) that they appear to impact
  • Requesting Workgroup agenda items for the specific EDT(s) that needs to be revised based on the new official coding guideline(s) [Workgroups should try to meet at least twice a month]
  • Ensuring that the clinical department/area that utilizes the EDT understands why the revision is needed (i.e., the official coding guideline’s impact on the EDT)
  • Sharing feedback from the coding specialists once the revised EDT is implemented.

In their, “Integrity of the Healthcare Record: Best Practices for EHR Documentation (2013 update),” AHIMA recommends that HIM professionals be included on the EHR design and implementation team to ensure the end product is compliant with all billing, coding, documentation, regulatory, and payer guidelines.7 Since EDTs are a component of the EHR, HIM professionals must ensure that EDTs are also compliant with coding guidelines, which means that EDTs must be evaluated whenever an official coding guideline is added or revised.

  1. 1. AHIMA Practice Brief. “Electronic Documentation Templates Support ICD-10-CM/PCS Implementation (2015 update)” (Updated June 2015). http://bok.ahima.org/doc?oid=107665#.Xz2XQ-hKg2z
  2. AHIMA. “Electronic Documentation Templates Support ICD-10-CM/PCS Implementation. Appendix A: Electronic Note Title and Template Policy Considerations.” Journal of AHIMA83, no.10 (October 2012): expanded online version. http://bok.ahima.org/doc?oid=105701#.Xz2XcuhKg2x
  3. American Medical Association, “Frequently Asked Questions – Surgery: Digestive System,” January 2017 CPT Assistant.
  4. Ibid.
  5. Ibid.
  6. Ibid.
  7. Ibid.


Lolita M. Jones (lolitamj@iquerydata.com), MSHS, RHIA, CCS, is a consultant and the principal of iQueryData.com. 

Leave a comment

Send a Comment

Your email address will not be published. Required fields are marked *