Documentation help

kwade30

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Shawnee, KS
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Hi there - I recently started a new job with a private practice and one of the physicians dropped some surgeries off to me yesterday. Three of them are the same type of surgery done at a surgery center and he has it set up with them that the surgery is already pre-typed up for him and there's a couple of fill in the blank spots (none of which are in the actual description of the procedure) for laterality, DOS, and age/sex of pt. I know this can't be right/legal - I've been doing a lot of research since I started here and now I have yet another scenario to research - just wondered if anyone had anything already handy they could share with me that I can give to my physician in writing when I discuss this with him?
thanks!
 

Pam Brooks

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This is not uncommon. The OIG has tasked all CMS contractors to pay attention to EMR generated documents and the associated bills, but of course the contractors can't know who is documenting inappropriately, what software, or even if the documentation represents the service. Look at the OIG work list for the past several years. This is addressed frequently, so at some point, surgical centers and their physicians will be looked at. It's up to coders to help educate our providers about how risky this can be.

I'd sit down with your provider and point out any discrepancies, examples of cloning (where every patient's chart looks the same), and blatant errors (this never happened....) and let them know that that is both a compliance issue and a patient care issue. Offer to assist in auditing his documentation within the software and work with the software analysts to make sure that each patient's note represents exactly what happed in the operative session. Then point out that when he signs off on the documentation, he is authenticating under the scope of his license, that the report is valid and accurate, and that he's placing himself at risk if there should be a payer audit, a patient complaint (where the patient recognized that certain things weren't done and complains to the insurance company) or an audit of the surgical center where he performs his surgeries, because they are billing out their surgical services using the same bogus note.

I encourage you to do this in a helpful and non-judgmental manner, because most of the time physicians don't even realize this is an issue. They're all busy, and when the software companies tell them that the documentation practically does it for them, they're all happy about that--then of course, we tell them otherwise. Good luck with this.
 
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We actually updated our software to prevent "copy and paste" for parts of the narrative/note sections. Other areas we changed so that the provider had to choose from drop down boxes; for example, if there was no change in meds, the provider can select "No" when asked if a change in meds has happened, and it will then populate the medication list and information onto the active encounter's note. Of course we rolled it out from the standpoint that by having these drop down boxes, less time is spent blah blah blah. No need to rock the boat if you don't have to.

Audits for the "copy and paste" problem ALWAYS end up badly. We had to terminate one of our providers because he copy/pasted the same exact note, WITH PHI from patient zero, into multiple other patients' charts.
 
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