Thanks for the reply. I think that my concern is that they will miss the basic elements. Unfortunately, before we created a paper template in the office to help them meet the basic requirements some of the notes often consisted of "return prn" on their followup visits and that was about it. I would just like something that listed the basic categories CC: HPI: ROS: EXAM: LABS/TESTS REVIEWED: ASSESSMENT/PLAN, and prompts that would enable them to code by time if it is appropriate, and an area that enabled them to write down what tests were reviewed, and if they personally looked at the films/discussed the case with other providers, etc. I just want something that will not put them back to the same level as writing on a blank piece of paper. I do know what you are saying because we have seen some systems that give extensive "canned information" and it would seem that it would be so easy just to continually cut and paste, and it would be very easy to forget to edit these areas to what is appropriate, and they could be noting things that they are not really doing for this particular patient. They just really need basic prompts to jar their memory in a busy office to note things that they are actually doing. If categories were listed that met Medicare's auditing requirements, it would really solve many problems. I think that many doctors are not compliant because they don't understand that everything is not a four or a five level. It is hard enough for a coder to try and count all the bullets, or if they use the 95 rules you have so many gray areas. Many doctors just guess at a code in a matter of seconds at the end of the contact. They are not sure if it meets the requirements of a consult, or a follow-up visit, or a new patient, etc., and especially since some plans allow consults and others don't. They certainly don't have time to analyze all of the billing criteria in a matter of seconds. I think this is as big of a problem as having too much canned information. So far I see these electronic systems either go overboard with information that they put in their system or the free ones are not compliant enough, and so I guess my original concern remains and that is if what the patient initially fills out which includes (ROS info, PFSH etc.) info will that still count as a full review even if it is not mirrored in the EHR system for that visit. I believe all of the papers that they fill out will be scanned into the chart.
Thanks for the response. I am sure as an auditor you have seen it all! You have excellent comments. I just wish these systems would meet somewhere in the middle with their features.