Use of a template to improve documentation and coding.
OBJECTIVE
Accurate assignment of evaluation and management (E&M) codes is a challenge for physicians. Having guidelines close at hand during patient visits might improve appropriateness and accuracy of E&M coding. We developed a template based on a clinical prediction rule for group A beta-hemolytic streptococcal (GABHS) pharyngitis to improve documentation and coding decisions.


METHODS
Fifty office visits for sore throat were documented using templates and were compared with 50 sore throat visits that were documented using progress notes. We counted history and physical examination items and compared the level of service charged to the level of service supported by the note.


RESULTS
Significantly more history of present illness and physical examination items were recorded on templates. Decisions related to treatment for patients with a low probability of GABHS were also improved by the templates. Templates had no effect on billing and coding errors.


CONCLUSIONS
The template resulted in more-thorough documentation but had no effect on coding and billing errors relative to progress notes.
Rose
E A
EA
Department of Family Medicine, Wayne State University, Detroit, MI 48235, USA. erose@med.wayne.edu
Deshikachar
A M
AM
Schwartz
K L
KL
Severson
R K
RK
D000328:Adult; D005260:Female; D005568:Forms and Records Control / Q000592:standards; D006801:Humans; D008297:Male; D008487:Medical History Taking / Q000379:methods* / Q000592:standards; D008499:Medical Records / Q000592:standards*; D016347:Medical Records Systems, Computerized; D010612:Pharyngitis / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology; D017410:Practice Guidelines as Topic / Q000592:standards*; D013290:Streptococcal Infections / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy