CMS working out details of electronic template

Providers say they'd like a paper option, too
Friday, April 13, 2012

BALTIMORE - Providers who want to print a hard copy of the electronic clinical template and give it to physicians to fill out during the face-to-face exam should be careful, CMS says.

During an Open Door Forum April 10, CMS officials said they're still working to ensure that the template, which will take the form of a series of prompts in the electronic health record (EHR), will be considered part of the patient's medical record.

"Most of us feel that it's really clear that (the electronic version) would be part of the patient's medical record," said Melanie Combs-Dyer, deputy director of the Provider Compliance Group at CMS. "But would it be considered part of the patient's medical record by all of the auditors? We recognize that is a really key question to get answered before we can say that our job is done."

CMS first announced plans to develop an electronic clinical template in March.

It was apparent during the call, however, that some providers would like to see a paper version of the template, something CMS is not currently planning to do. Callers who asked if a printed version of the template could be used were told that physicians could document however they like, as long as the physician's narrative meets Medicare's requirements.

"Any format that a physician or other practitioner chooses to use to establish medical necessity is fine with us," said Dr. Susan Miller, a medical officer in CMS Office of Clinical Standards and Quality. "We just need to see that the information is there."
In the past, there have been issues with paper forms or templates because of the limited space provided for answers prevented doctors from being thorough, said Combs-Dyer.

"Physicians tend to think they need to limit their answers to that 4-inch line or that checkbox," she said. "And sometimes there's not enough information provided in those kinds of formats for the contractors to make an affirmative determination about that claim."

CMS expects to post a new draft of the electronic clinical template based on stakeholder feedback before the next Open Door Forum, scheduled for June 14. Comments and suggestions regarding the current draft can be sent to

View the template draft.


I would like to add an additional word of caution to any suppliers considering printing a paper copy of the electronic template and providing it to physicians. Even though the template is being designed by CMS, its intent is not for this type of use, and therefore could be considered a supplier generated form. Supplier generated forms, as you may be aware, are not considered part of the medical record. In addition, even if a paper copy of the form is approved for use by CMS, the risk is that the form will not stand alone in the event of an audit. The concern is that auditing contractors may want to see further evidence supporting the information documented on the form in the patient's medical history; similar to how the medical necessity information on a CMN must be independantly substantiated in the physician's chart notes (the CMN does not stand alone). I am hopeful that direction on these points will be clarified by CMS in a future open door forum.