Ophthalmology and Optometry Coding Alert

Question: I am the new office manager at an eye care practice that uses EHRs that have templates in them that auto-populate certain notes from previous visits. I've heard this is not recommended, but the staff here says they've had no problems. Can you advise?

Codify Subscriber

Answer: Be very wary of documentation templates that come with the software, but not all templates are forbidden.

Some EHR systems do auto-populate parts of the medical record with information that is not specific to the patient, especially in the HPI section, and that is to be avoided. Certain payers have very specific guidelines warning practices against this. For example, following is Noridian's statement about such "auto-populate" features:

"Auto-populated paragraphs provide useful information such as the etiology, standards of practice, and general goals of a particular diagnosis. However, they are generalization and do not support medically necessary information that correlates to the management of a particular patient ... Credit cannot be granted for information that is not patient-specific and date-of-service-specific."

Therefore, if you work directly with your EHR vendor to create customized documentation templates for your practice, you can get better data from clinicians which will help you code and bill correctly and reduce compliance risks. Just be sure the templates are general in nature, as noted in the Noridian policy above, and are not populated with patient-specific and date-of-service-specific data.