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Cut and Paste

  1. #1
    Default Cut and Paste
    Medical Coding Books
    I have a physician who is questioning how much if any of his office notes can be cut and pasted from a previous note. We are a multi-physician practice and every physician has their own opinion on the subject. Some physicians are only taking medication lists from note to note and others are copying and pasting the diagnosis and assessment (making necessary changes of course). I also have a doctor who reads the prior note and makes necessary changes.

    Is anyone else experiencing these issues?

    Thanks in advance.

  2. #2
    I am not aware of any official limitation as to how much is too much but there has to be some sense of reason.

    The note must be unique to the visit it is supposed to document, the information has to be pertinent to this visit. Something that was done the prior visit may be resolved and copying it over would be redundant to say the least. The copied information must be reviewed and edited to make sure it reflects "today's" visit accurately.

    There was an article in the September 2006 Medicare B resources, see page 100. This is NHIC - your carrier may have something similar. Go to the part that starts with "Honest reporting" - bold font, middle of page.

    Hope this is useful.
    Karolina, CPC, CPMA, CEMC

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