To encourage better documentation, she says, many practices have created a form or template for progress notes. The forms allow a physician to quickly record the services provided and refer to other documentation in the patient record. The coder can then review the physician's list and determine which level of service should be reported.
The most effective forms, Falbo says, are designed to reflect specifically the clinical focus of the individual practice and follow the sequence of a typical patient encounter. In addition, she advises using the 1995 documentation guidelines (DG) for E/M services because the exam component guidelines are more lenient than the 1997 guidelines and are more conducive to a physician's clinical protocol. The 1995 guidelines focus on organ systems as opposed to the bullets required in the 1997 DGs. "The bullet concept caused more confusion for the physicians and limited their clinical autonomy in examining the patient," she says. "In addition, the newly proposed documentation guidelines that will be implemented soon are based on the 1995 documentation guidelines."
Standardized Notes Have Pros, Cons
"There is a lot to be said for using standardized templates," Falbo says. "Most family physicians I know have educated themselves about the need for thorough documentation. But when they are seeing a patient, the focus of their attention is patient care, not coding. And that is how it should be. A progress note form can be a valuable tool to help prompt them to consider what needs to be documented about the nature of the presenting problem. It captures crucial, relevant information."
Other coding experts recommend that family practices approach templates with caution. "There is a certain amount of controversy surrounding use of these forms," says Garnet Dunston, CPC, MPC, president and CEO of the coding services firm Dunston Enterprises Inc., in Phoenix, and past secretary for the American Academy of Professional Coders National Advisory Board. "It is relatively simple to check off a list of items on a form. But this might not represent work that justifies a higher level of service."