Use of a template to improve documentation and coding.

Area of Science:

• Medical Informatics
• Clinical Documentation Improvement
• Healthcare Quality

Background:

• Accurate evaluation and management (E&M) coding presents a significant challenge for physicians.
• Clinical guidelines integrated into patient visits may enhance E&M coding accuracy and appropriateness.
• A novel template, derived from a clinical prediction rule for group A beta-hemolytic streptococcal (GABHS) pharyngitis, was developed to aid documentation and coding decisions.

Purpose of the Study:

• To assess the impact of a clinical prediction rule-based template on physician documentation and E&M coding for sore throat visits.
• To determine if enhanced documentation through templates improves the accuracy of coding and billing.
• To evaluate the effect of templates on treatment decisions for patients with suspected GABHS pharyngitis.

Main Methods:

• A comparative study involving 100 office visits for sore throat.
• Fifty visits were documented using the developed template, while the other 50 used traditional progress notes.
• Analysis included counting documented history and physical examination items and comparing billed service levels to supported service levels.

Main Results:

• Templates significantly increased the recording of history of present illness and physical examination items compared to progress notes.
• The templates positively influenced treatment decisions for patients with a low probability of GABHS.
• No significant difference was observed in coding and billing errors between the template group and the progress note group.

Conclusions:

• The implemented template led to more comprehensive documentation of patient encounters.
• Despite improved documentation, the template did not demonstrate a reduction in coding or billing errors when compared to standard progress notes.