Wiki Duplicate Documentation Progress Notes

[toria11]

I have a provider that will see a patient on two separate days in the hospital, but the hospital progress note documentation is exactly the same. How would you approach this? Do you code it again and assume the situation was unchanged or do you inform the provider it can't be billed when the documentation is clearly just copy and pasted from the previous day?

 

[thomas7331]

I would code it as is, since the provider has signed and attested that the documented is accurate, and I've always felt it's outside the scope a coder's role to unilaterally decide that a provider's documentation is invalid. However, I would also report it to my manager and/or compliance officer and ask for their guidance on how they want you to handle it. Overuse of copy/paste and 'cloned' documentation will pose an audit risk to the practice, and management needs to be aware of this and (hopefully) develop a plan for how to address it.

 

[amyjph]

Good advice from Thomas. When rounding daily, sometimes the status might be the same. Are the vitals exactly the same though, nothing happened overnight? Nothing changed at all? I agree, talk to a manager or supervisor about it. Is it happening on multiple patients across a time span where there is copy/paste and cloning constantly? Definitely can become an issue. If you have a good relationship with the provider, you could ask depending on the volume of patients and practice, etc.