E/m auditing


Best answers
When an established patient comes in does the physician have to update their exam or can they just carry it forward from a previous visit?

If they change/add one thing to the exam (one section not the whole exam) does this allow them to use the complete exam from the previous visit?

On the HPI I know they have to update it every visit and cannot copy and paste it from a previous visit but if a physician does I assume we cannot count the HPI when auditing the chart?

Any help or links for written information would be wonderful as I need to be able to explain to the physician why it cannot be copied and pasted with no changes made.

Thank you so much for any input


True Blue
Best answers
A good place to start is with some of the CMS and OIG publications that address the use of copy and paste. I've added links to a couple of documents below.

From the OIG report: "When doctors, nurses, or other clinicians copy-paste information but fail to update it or ensure accuracy, inaccurate information may enter the patient’s medical record and inappropriate charges may be billed to patients and third-party health care payers. Furthermore, inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims." It should go without saying that a provider cannot 'carry forward' an exam. The provider's signature on the medical record is a legal attestation of the work they performed at that encounter and their certification of the accuracy of the information. There is nothing wrong with using a template, but to copy and paste without customizing the information to the particular patient and visit is a very risky practice.

With respect to auditing, I always caution providers that if it becomes obvious to an auditor that copy/paste is being used too frequently or carelessly, it decreases the auditor's confidence in the accuracy of the notes they are reviewing and that's not a situation you want as it can lead to an expansion of the audit and closer scrutiny of all of the provider's records in the future.