Clinical template
Medical Billing and Coding Template
Billing codes are only as good as the note. In Canada that usually means a provincial schedule of benefits (OHIP, MSP, RAMQ, AHCIP, and the others) plus diagnostic codes your ministry expects. In the United States it usually means CPT for the service and ICD-10-CM for the diagnosis. This template helps you record what you did so a code can be justified. It does not teach you to bill a higher level than the visit.
Two systems, one documentation job
A Canadian family physician and a US internist can see the same sore throat and leave with different claim files. The clinical note still has to answer the same questions: who was there, what was done, why it was needed, how long it took if time-based, and what diagnosis you are attaching. Coders and ministry assessors read that note when a claim is pulled. So do colleges.
| Canada (typical office) | United States (typical office) | |
|---|---|---|
| Service code | Provincial schedule (e.g. OHIP A007, MSP 00100 — examples of the idea, not current fees) | CPT / HCPCS for E/M or procedure |
| Diagnosis | Provincial diagnostic code list or ICD as required by the plan | ICD-10-CM |
| Payer | Ministry of health; some third-party (WSIB/WCB, private, uninsured) | Commercial, Medicare, Medicaid, self-pay |
| What the note must support | That the insured service described in the schedule actually happened | Medical necessity and the E/M or procedure level billed |
No upcoding
Do not add history, exam, or time you did not perform to justify a higher code. Do not pick a more complex diagnostic code because it pays more. If a visit was simple, bill the simple code. Scribeberry's billing lookup, if you use it, is a suggestion. You verify it against the current schedule or CPT book and against the note you sign.
Blank billing addendum template
Keep this as a short block after SOAP or as a billing sheet your clerk sees. The clinical note stays clinical. The addendum is the claim's memory.
Encounter billing worksheet
Date of service / location (office, ED, virtual, home, LTC): Clinician / billing number / group: Patient provincial health number or US payer ID on file: Y/N Visit type: new / repeat / consult / procedure / preventive / extra time Clinical note reference: SOAP / consult / procedure note signed: Chief reason for the claim (one line): Service(s) actually performed 1. Description in schedule/CPT language you would defend: Time: start–stop or total minutes (if the code is time-based): Counseling / coordination minutes (if that is how you are billing): Procedure details (site, laterality, device) if any: Tray / tray tray / tray — only if you used them and the schedule allows: Diagnosis for the claim Working diagnosis in your words: Code you intend (provincial diagnostic or ICD-10-CM) — verify current file: Second diagnosis only if it affected this visit: Payer notes Public plan / third party / uninsured / WSIB-WCB / MVA: Other coverage (see coordination of benefits): Referring clinician if consult rules require it: Suggested code from tool (optional) Scribeberry or EMR suggestion: Verified against current schedule/CPT: Y/N by: Final code(s) submitted: Do not submit if Note does not describe the service / time missing for a time code / wrong patient / duplicate same-day without an allowed modifier or second-visit rule.
What assessors look for
Provincial audit letters and US payer recoupments often start with a mismatch: a complex consult code on a three-line note, a procedure without a site, a virtual code on a visit that reads as in-person, or two full assessments on the same day with no explanation. Your defence is the signed record, not a memory of how busy the clinic felt.
- Time-based codes need start–stop or total minutes in the note, not only on the claim screen.
- Consults need a requesting clinician and an opinion, where the schedule requires that.
- Virtual visits need the modality (phone vs video) your plan distinguishes.
- Procedures need indication, site, and what was done, even if the fee code is familiar.
- Diagnostic codes should match the problem you managed today, not an old CPP entry you never touched.
Fee schedules change. A code number in a blog post is stale the day after a ministry bulletin. Teach your staff to open the current OHIP Schedule of Benefits, MSC payment schedule, or CPT manual — not a printed 2019 cheat sheet on the wall. This page deliberately does not list live fee values.
Example — Canadian office visit (fictional)
Family medicine billing addendum
Ontario community clinic. 15-minute in-person visit. Fictional. Codes below are placeholders for the idea of matching note to schedule, not a fee quote.
Service date: 2026-08-28, office. Note: SOAP signed — acute mechanical low back pain, occupational, Form 8 completed. Performed: in-person assessment, counselling on activity and red flags, WSIB Form 8. Time: 14:00–14:16. Not billed as counselling-predominant. Diagnosis for claim: lumbar strain (use current provincial diagnostic code; verify). Payer: OHIP for the visit; WSIB form may have a separate form fee per current schedule — clerk to confirm, not assumed here. Tool suggestion: [schedule assessment code] — verified by clinician against current OHIP schedule before submit. Not billed: intermediate or special visit premiums (none applied). No upcode for 'complexity' — single problem, no red flags. COB: patient also has private physio benefits; not billed here. Other-coverage field updated on registration.
Scribeberry billing lookup
If you use Scribeberry's billing lookup, treat the output as a draft code attached to the draft note. Wrong laterality, a missing time statement, or a ministry bulletin you have not read will still produce a bad claim. The person whose billing number goes on the card is the person who checks.
Draft the note that supports the claim
Scribeberry drafts the encounter note from the visit. Billing lookup, when you use it, is a suggestion you verify against the current schedule or CPT and the note you sign. Smart Push into Accuro, OSCAR, Jane, or any web EMR. Pro is $99/month after the free trial.
Frequently asked questions
Is medical coding the same in Canada and the US?
No. Canadian office claims usually use a provincial schedule of benefits plus the diagnostic codes that plan requires. US office claims usually use CPT for the service and ICD-10-CM for the diagnosis. The note still has to describe the service in both places.
Can software pick my billing code for me?
It can suggest. You verify against the current schedule or CPT and against the signed note. Submitting an unchecked suggestion is still your claim.
What is upcoding?
Billing a higher-intensity or higher-priced service than the record supports. Do not add undocumented history, exam, or time to chase a higher code.
Does a SOAP note automatically justify the bill?
Only if it describes the service you claimed. SOAP structure helps, but a three-line SOAP will not defend a complex consult code.
Templates
