Provider's Documentation - Understand The Risk Involved With Clinical Plagiarism & Medical Necessity

Providers continually are challenged to provide proper documentation of their services to justify level of an Evaluation and Management (E&M) service they have selected or the code for a procedure or surgery.  EMR’s provide “dot phrases” and “smart phrases” which are brief keystrokes that providers make that insert a predetermined text into the record.  Cut and paste is taking text from one record (that patient’s or another’s) and inserting it in its entirety into another second.  Generally, this action is problematic because it is not documenting original work done on the patient.  This brings up the question of medical necessity and also clinical plagiarism. 

Insurances have stiffened their position on physicians notes that are duplicative in whole or part day after day.  They have commented more on the practice of cut and paste.  More studies on the origins of progress notes and their lack of originality are coming out as well.  Note Bloat continues in spite of major changes to documentation rules for all Evaluation and Management Services.  The changes to documentation requirements for Evaluation and Management services from CPT in 2021 and 2023 were specific and dramatic.

What is your provider’s documentation like?  How much of it is unique information about today’s visit? How do you analyze charts to see if you have a problem with a lack of originality in notes about a patient? Are your procedure/operative reports original to the patient?

Webinar Objectives

• Are you allowed to bring in documentation from a prior note?  Which type and how much are allowed? Is this a compliance issue?
• CPT saw changes to Evaluation and Managements coding and documentation guidelines in 2021 and 2023.  Should this and could this decrease the volume content of your provider’s notes
• Are pre-populated text entries a problem?  When are they not?
• Why does the old system of documentation put you at more risk than the new?  It’s all in the guidelines

Webinar Agenda

• When Electronic Medical Records (EMR) systems were created, one of the selling points was expediency in documentation.  I would challenge that point in talking with today’s providers.  Why?
• A progress note on a patient should have information since the last visit until today’s, what has changed?
• What is the difference between the old H&P and the new “medically appropriate history and exam”?
• What is new about medical decision making and its documentation to show support of the level of service billed for the service today. 
• What is meant by original work by the provider for this unique patient on this unique date of service.
• EMR’s have taken the often too short written note by the provider and replaced it with pages and pages of information
• How does a note meet medical necessity? or is it just yesterday’s note with a different date on it?    
  • Does it contain sections of information copied from another patient or from a consultant’s note?  Again compliance issues and potentially clinical plagiarism.  
• What does your medical record software ALLOW providers to do? 
• Finding and analyzing this information as well as what different payers have said about Cut and Paste and Clinical Plagiarism leads to a better understanding of the issues.  This will help listeners to form a plan for analysis of their records and come up with an action plan in working with their providers.

Webinar Highlights

• Where does medical necessity fit into this puzzle?
• With the major changes in E&M service requirements what “should’ current documentation in a patient’s record contain?  Tips on how to train this information to your providers
• Do your providers know what E&M visits in 2023 should look like?
• What to look for when reviewing a record when concerned about copied, cut & pasted or imported documentation to help you spot problems
• Coding issues (diagnosis and E&M) that arise from documentation that is cut & pasted
• A quick conversation about Split Shared visits

Who Should Attend

Coders, Billers, Auditors, Office Managers, Office Administrators, Nurse Practitioners, Physician Assistant, Physician