Insurances have stiffened their position on physicians notes that are duplicative or that have portions they identify as having been cut and pasted.  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.

Physicians in the hospital like to have a running note for a patient. They say it allows them to see the patient’s progress. But a note without clear content from today’s visit is a problem. The duplication of prior documentation to make it easier for physicians starts a bad sequence of events in making a note that may not have easily discerned work for the billing physician for that date.

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?

Whether information is cut and pasted, pulled forward or entered with a smart phrase, compliance issues exist. What information IS ALLOWED to be incorporated in another day’s note will be discussed. What is allowed from a compliance perspective? Looking at one patient note may not give a reviewer the insight they need about the patient’s record and their provider’s habits with documentation. 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 webinar 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 Objectives

• How much of a record documentation is imported from old notes?  Is this a compliance issue?
• How changes to Evaluation and Managements codes for 2021 and 2023 should have decreased the volume content of your provider’s notes
• Are pre-populated text entries a problem?
• Understanding why using the old system of documentation puts you at more risk than the new

Webinar Highlights

• 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? 
• A quick conversation about Split Shared visits 
• 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
• Where does medical necessity fit into this puzzle?

Who Should Attend

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