General Question for the Week of November 18, 2019

Question:

Could a doctor use template documentation like the following in their reports? “IVC, Aorta, Pancreas: Not well seen given a combination of bowel gas and patient body habitus.” This documentation is in all of his US abdomen reports.

Answer:

Templates can be used, but doctors must be careful to adjust the template documentation as necessary for every patient. It is not appropriate to use template documentation such as the statement you provide above on all patients because it will not be true for every patient. Many exams will allow the inferior vena cava (IVC), aorta, and pancreas to be seen, and the doctor must document appropriately for each individual exam. Medicare auditors are looking for things such as this that indicate inappropriate use of templates or the electronic health record (her). The same wording on every exam raises a red flag for the auditor.