Use of a template to improve documentation and ceding

Background and Objectives: 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 co ding. We developed a template based on a clinical prediction rule for group A beta-hemolytic streptococcal (GABHS) pharyngitis to improve documentatio n and coding decisions. Methods: Fifty office visits for sore throat were d ocumented using templates and were compared with 50 soi-e throat visits tha t were documented using progress notes. We counted history and physical exa mination items and compared the Level of service charged to the level of se rvice supported by the note. Results. Significantly more history of present illness and physical examination items were recorded an templates. Decisio ns related to treatment for patients with a low probability of GABHS were a lso improved by the templates. Templates had no effect on billing and codin g errors. Conclusions: The templates resulted in more-thorough documentatio n but had no effect on coding and billing errors relative to progress notes .