Wiki Hospitalist's note carried forward from day to day with minimal changes

[nini82799]

As copying and pasting is legal, can credit be given toward an e/m level to a Hospitalist for parts of a note which has been copied from a previous note, such as the hpi and the physical exam? For example, if the physical exam is copied from the prior visit, by signing the current note, is the provider confirming the exam was performed as documented and is accurate for that date of service? I am questioning a 99233. The MDM is supported, and a comprehensive exam is documented, but the exam (as well as the history) has been copied from the day before.

 

[thomas7331]

There are no official coding guidelines that allow you to disqualify a part of the note based on the fact that it was copied or pasted from a previous note. I would recommend against downcoding just based on your own assessment without the backing of your organization. The physicians may not be aware that they are doing something inappropriate and it can create problems if you start penalizing them without making the aware of what you are doing in advance.

But overuse of copy/paste and cloned notes is definitely a compliance concern - CMS and the OIG have mentioned this in multiple publications. This is something you should bring to the attention of your management and/or compliance department and get their guidance. They can give you instructions as to whether or not it is appropriate to downcode to a lower level in these situations, and they can also address the problem with the physicians who are documenting this way.