The Centers for Medicare and Medicaid Services released revised instructions for review contractors admonishing them to review all medical record entries signed by physicians, even ones created using the Limited Space Templates from electronic medical records.
According to the guidelines, contractors are to keep in mind that progress notes alone from EMR templates are not acceptable documentation for medical examinations, according to the instructions.
While CMS does not prohibit or endorse templates, the organization discourages use of templates with limited options or check boxes as they made it hard for providers to meet all coding requirements.
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