A Rose by Any Other Name | EMR and Compliance

The blog post below, written in 2017, discusses the issue of copying and pasting in electronic health records. Since then, CMS has changed its stance on importing history and exam elements from other records, and about who may document the HPI. In the Physician Final Rule for 2020, CMS went further, and said

“We noted that this paragraph would specify that, when furnishing their professional services, the clinician may review and verify (sign/date) notes in a patient’s medical record made by other physicians, residents, nurses, students, or other members of the medical team, including notes documenting the practitioner’s presence and participation in the services, rather than fully re-documenting the information.

We also noted that, while the proposed change addresses who may document services in the medical record, subject to review and verification by the furnishing and billing clinician, it would not modify the scope of, or standards for, the documentation that is needed in the medical record to demonstrate medical necessity of services, or otherwise for purposes of appropriate medical recordkeeping.”

This is a significant change from prior CMS guidance.  See the article about the medical record documentation changes CMS has implemented.

Written in 2017: A physician once told me she wasn’t copying from one note and into the current note. She was importing the entire prior note and editing it, since her hospital policy doesn’t allow copying and pasting.

It reminded me of Juliet saying about Romeo, “A rose by any other name would smell as sweet.”

Electronic Health Records (EHRs) and copy/paste

I was reminded of this by an article in JAMA internal medicine published online May 30, 2017. It was a research letter titled “characterizing the source of text in electronic health record progress notes.”

The three authors, Michael Dr. Wang, M.D., Raman Khanna, M.D., and Nader Najafi, M.D. analyze inpatient progress notes to determine how much was copied, how much was imported and how much was manually entered into the progress note.

In a typical note, only 18% of the text is manually entered.

46% was copied and

36% was imported from another portion of the record.

Is this the new normal in documentation?

Auditing E/M services

A few years ago I attended a compliance conference and one of the speakers said that at their organization when coders reviewed notes they always reviewed the note prior before assigning a code.

For each section of the note – history of present illness, review of systems, past family, medical, and social history, exam assessment, and plan the coder noted whether it was:

• identical to a prior note,
• similar to a prior note, or
• unique

Obviously, this adds significantly to the time of reviewing the note.

The Documentation Guidelines themselves were written in 1995 and 1997, long before electronic health records were in frequent use. The guidelines state that:

a review of systems and past family medical and social history does not need to be re-recorded if there is evidence that the clinician reviewed those sections and updated them if needed.

A link to the CMS website where you can download a copy of the Guidelines is at the end of this article.

An OIG report defined both copying and pasting and overdocumentation.

According to the Office of Inspector General,

“Overdocumentation is the practice of inserting false or irrelevant documentation to create the appearance of support for billing higher level services. Some EHR technologies auto-populate fields when using templates built into the system.

Other systems generate extensive documentation on the basis of a single click of a checkbox, which if not appropriately edited by the provider, may be inaccurate. Such features can produce information suggesting the practitioner preformed more comprehensive services than were actually rendered.”

“Copy-pasting, also known as cloning, allows users to select information from one source and replicate it in another location.

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.”

That OIG report was entitled “CMS and its contractors have adopted few program integrity practices to address vulnerabilities in EHRs.”

You can download that report here to save the time and trouble of searching for it on the OIG website.

Some organizations have internal compliance policies about copying/pasting in the EHR

As coders, it is important for us to work with medical directors and administration to develop EHR policies that are compliant with government guidance.

We need to assess notes based on the policies that are in place. It seems clear to me that we will need to accept that parts of the note are going to be imported.

For example, a clinical summary may be carried forward from one note to the next. I wrote about the clinical in more detail in an earlier article.

I do not count the clinical summary as HPI and strongly recommend that after the clinical summary is imported into the HPI, the physician say, “since last seen….” That is where the HPI starts.

It’s important to read carefully to make sure that the imported and edited portions are accurate. In July of 2017 the note might say, “she is scheduled for her knee replacement next month in October 2016.” This is a clear indication that this historical note was imported but not edited.

As coders, we are not responsible for clinical quality of the record. Our job is to identify issues with copying/pasting and overdocumentation and bring it to the attention of the medical director, administration or compliance, depending on the organization in which we work.

But, when auditing a note, a coder has to decide what to credit for that note. If the HPI is identical to a prior note, with a word or two change, I am reluctant to credit it.

The physician was paid for that work at the prior visit. The level of service for the current visit should be based on the work done and documented today.

I’m going to discuss this in my upcoming webinar in September. It is one of the many gray areas in auditing E/M services. Members can sign up for free here.

Patient portal and access to medical notes

Patients now have access to all or part of the note for their office visit through a patient portal. This has sparked a flurry of patient complaints. Often, this is how administrators know there is a problem.

The patient reads their note, compares it to a prior note and questions the charge, because it is identical to a prior note in some sections. Or, because systems are noted as reviewed that weren’t asked or exam elements are documented as performed that weren’t examined. These patient complaints can serve as important feedback to physicians and management.

I am completely sympathetic to the difficulties of documenting in EHRs, the endless clicking, the onslaught of notifications and task lists. I hope the next generation of EHRs have less busy work for physicians, NPs and PAs and provide clinical records that are useful to physicians, nurses and other health care professionals.

Download a copy of the 1995 Guidelines from CMS’s website here.