Wiki Cloned notes-determining follow up levels

[cerullhon]

I have a Hospitalists that clones (copies and pastes) all his notes despite being told about this. I'm having a battle with myself on how to codes his follow ups. My Managers says to code per documentation which I do. Since his notes are cloned and his template is set for a COMPREHENSIVE exam each time (whether medically necessary or not), his follow ups are scored as level 3's. But what happens when he adds a paragraph to the top of the cloned note stating patient is improved and goes into detail about that? He then adjusts time spent from 35 or 40 minutes down to 25 or 30 minutes. All of this indicates to me a reduced level. I really struggle as these should be coded as level 2's even though the rest of the note scores a level 3!

I'm trying to justify scoring these as level 2's because the E/M guidelines are just that...guidelines. The Medical Necessity just isn't there to ethically score any higher. But yet.........when you have 20 pages cloned from when the patient was in ICU..........what does one do?

I'd surely appreciate any guidance in this.
Thank you.

 

[cmk112@gmail.com]

I have a Hospitalists that clones (copies and pastes) all his notes despite being told about this. I'm having a battle with myself on how to codes his follow ups. My Managers says to code per documentation which I do. Since his notes are cloned and his template is set for a COMPREHENSIVE exam each time (whether medically necessary or not), his follow ups are scored as level 3's. But what happens when he adds a paragraph to the top of the cloned note stating patient is improved and goes into detail about that? He then adjusts time spent from 35 or 40 minutes down to 25 or 30 minutes. All of this indicates to me a reduced level. I really struggle as these should be coded as level 2's even though the rest of the note scores a level 3!

I'm trying to justify scoring these as level 2's because the E/M guidelines are just that...guidelines. The Medical Necessity just isn't there to ethically score any higher. But yet.........when you have 20 pages cloned from when the patient was in ICU..........what does one do?

I'd surely appreciate any guidance in this.
Thank you.

How did you end up handling this?? I have found myself in similar situations myself.
Thanks

 

[CarmonaEnterprises]

Hello cerullhon & cmk112,
To be straightforward with you, highly recommend to see if the chart notes are accurate with the nature of the visit, in some cases its ok to a certain point to copy notes from a previous encounter, however if you see that those notes are not genuine to the encounter for that particular DOS, then seek that options at the place you work to help resolve this if there are no resources available then the best thing to to do is to transfer to another department or resign. The most import thing as a licensed coder and heathcare professional is to keep your license valid and credible and there are plenty of entities and organizations that do follow the rules.

In the Fraud Waste and Abuse world of healthcare its called broiler-plate or template billing and yes many providers do get into trouble over this and these interventions can carry over from the providers to the coders, billers or anyone else involved in this. An external audit would take place and based on the findings for fraud waste and abuse, the outcome will be determined accordingly.

Best of luck, Jeff