Actually, since I am the one building all the templates, I would like to make a comment on my approach to see if this works for anyone else. I am categorizing each aspect of the office visit in a way that corresponds to the e/m coding guidelines (ie History, physical, medical decision making) When I create a h istory or physical exam template I label it brief, detailed, or comprehensive. Then it is only up to the MD to choose the appropriate level based on the medical decision making. Of course we are planning to embed "points" in each template data element in a future version and then count the points up to offer an auditing check on the code level.
CSH
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