Wiki Repetitive notes

[REGINALD068]

Good afternoon
I have several Provider's whose notes are obviously a copy and paste. This is a grave concern for me, when auditing their coding, because the notes are never customized to fit the current visit. From the consultation or IE, and every F/U visit, the wording doesn't change, so when I'm checking to see if they're meeting the required elements for the level of service billed, it's all incorrect. How do I get them to document exactly what was done with the patient on any given visit?
Thanks

 

[Chelle-Lynn]

This is a great training opportunity for your site! And a good catch by you! Hopefully your office as a compliance officer or representative. If so, I would bring this issue to their attention for training with the provider in regards to concerns with copy and paste without update. Specific examples are always the best source for training, so make sure to provide these to your compliance representative.

Using documentation from the OIG, CMS, and other publications in regards to the red flags that occur with copy and paste as well as the possible financial impact will be good references for explaining your concern on these issues.

 

[Pathos]

CMS has come out and allowed Macros to be used when documenting patient charts, however there is a fine line between overusing Macros and Cloning of notes. Obviously if the information entered by macros is incorrect or has nothing to do with the present encounter, then there is an integrity issue and should be followed up with your Compliance Officer. Even if the practice you work for might be small (or big), and you don't want your practice to make OIG's headlines after a comprehensive audit.

However, before you go to your Compliance Officer (and anyone else higher up than you), make sure you have the OIG, CMS, etc. articles to back up your claim. Hard cold facts tend to work much better than a "he said, she said" scenario.

This article from CMS (December 2015) explains some of the pitfalls when documenting in any EHR system.

Here's an article from AAPC about Cloning as well.