Electronic medical records have made it easy for providers to introduce documentation into a patient’s record that jeopardizes the integrity of the entire visit documentation and thereby reimbursement for the visit. A 2017 study of over 23,000 patient progress notes for one particular software showed that only 15% of the text was entered manually. The rest was either cut and pasted or “imported”.
  
Documentation of a patient’s visit needs to be specific to that patient by that provider on that date of service. Bringing in text from another visit, produces a record that does not meet that standard. If the documentation is corrupted by the cutting and pasting of text, then the visit, on audit, will fail. That means no reimbursement. Payers have been warning providers about a lack of original documentation and are now doing audits of sequential dates of service to compare records and look for cutting and pasting.
  
It seems providers have become bolder in their cutting and pasting of text into a record. Some are inserting an entire paragraph of text pulled from a library of smart phrases. Procedure reports for minor surgeries like a lesion removal are common examples. Others are so bold as to copy text from another patient record. Inserting text into a record that is copied from another record has been called Clinical Plagiarism.
  
What is your provider’s documentation like? Do any of these examples sound familiar? This webinar will give you some tips on how to look at documentation with a critical eye for this compliance issue with serious financial ramifications

Webinar Objectives

• Is the copying or cutting and pasting of text from a library of “normals” fraud?
• If the documentation from the Review of Systems is in conflict with other parts of the chart documentation, is that a problem?  What are the consequences?
• What information can be brought into a new date of service from an old note?
• How do the new E&M Guidelines for office make it easier to retrain physicians to create original documentation for their visits?

Webinar Agenda

Duplicating text from prior documentation is the start of the process. The words can be entered via a smart phrase or pulled forward with a series of keystrokes or just cut and pasted. However, they get there the text inserted can create a compliance problem. What information is allowed to be entered into another date of service’s note? When does it cross the line into a compliance issue?

Auditing one note of a patient’s record is not going to give the reviewer the information needed. Tips on simple ways to recognize inappropriate documentation will be shared. We will also be looking at areas that electronic record software is contributing to documentation problems.

Finding and analyzing this information as well as what different payers have said about Cut and Paste and Clinical Plagiarism leads to a better understanding of the issues. This will help attendees to form a plan for analysis of their records and come up with an action plan in working with their providers.

Webinar Highlights

• What “should’ current documentation in a patient’s record contain? Tips on how to train this information to your providers
• What to look for when reviewing a record when concerned about copied, cut & pasted or imported documentation to help you spot problems
• Coding issues (diagnosis and E&M) that arise from documentation that is cut & pasted
• Where does medical necessity fit into this puzzle?
• How did the changes to Office E&M services for 2021 affect this topic and your providers documentation?

Who Should Attend?

Coders, Billers, Auditors, Office Managers, Office Administrators, Nurse Practitioners, Physician Assistant, Physician