Wiki 2nd REQUEST ADVISE PLEASE!!

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How to you go about coding for E/M services (mainly inpatient) when the physician uses a templete and everything (even the exam) is consistant from one DOS to another? Do they get credit??
 
That is considered "cloning" and can throw up a red flag, it is not wise to copy and paste the same information over and over. Your physician needs to make each document unique from the other previous notes.
 
I know it's considered cloning but my question is do you go ahead and code and be ready for an audit or do you say they are not billable because they are clones of the orignial dos?
 
Red Flag!

This is a huge audit risk. As a matter of fact, the coders in my facility recently refused to post charges for a provider who was obviously copy/pasting. If all of the information in an inpatient record is verbatim from day to day, how do you prove medical necessity for the stay? And if they are discharged in the same condition they were admitted in, that documentation would be begging for malpractice suits. My best advice is not to bill this. Your certification is at stake if you bill something you know is incorrect. Talk to your provider about the risks of his/her documentation. Chances are, he or she is completely capable of providing more detailed information about the case and will do so once they understand the importance of the documentation.
 
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