The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.
When Saving Time Becomes Expensive
Love them or hate them, electronic health records (EHRs) are now an integral part of the health care delivery system. Gone are the days when patient records had to be deciphered because of legibility issues. We now have pages and pages of very legible notes on a patient, but caution must be exercised in how you use the tools available to you.
A 2013 Office of Inspector General (OIG) report reviewed the Health and Human Services’ (HHS) efforts to promote EHR adoption and stated that HHS “focused largely on developing criteria, developing meaningful use and administering incentive payments. It gave less attention to the risks EHRs may pose to the program integrity of federal health care programs.” As a result, the OIG raised questions about what actions EHR software allows physicians to take and the potential impact on program integrity.
Phrases like “note bloat” have been created to represent some of the lengthy notes seen in patients’ charts. The use of copy and paste or cloning frequently leads to these lengthy and sometimes meaningless patient notes. While saving time, notes created with recycled text can create problems for both the physician and the patient. Repetitive or excessive notes can lead providers to lose confidence in the note all together. When physician’s orders for a patient are based on information that may not be current, or are inaccurate, consequences can occur for both the patient and the physician.
Studies indicate that the use of cut and paste tools is significant. According to a 2013 report by the American Health Information Management Association, 74 to 90 percent of physicians use the copy and paste function in their EHRs. Further, the study found that between 20 and 78 percent of physician notes are copied text. Another study from Case Western Reserve University School of Medicine in 2012 showed 82 percent of progress notes created by medical residents contained 20 percent or more of copied and pasted material from patient records. In addition, 74 percent of progress notes created by attending physicians contained 20 percent or more of copied text. These bad habits are being passed on to our new physicians. The number one response I get from physicians on this topic when asked about the use of cut and paste tools is that they do it due to time constraints. The practice may save a little time, but could be very costly.
Payers are beginning to take notice. They have analyzed the situation and come to the conclusion that cut and pasted notes may show work that was not done. For example, cloning the exam section allows for a physician to introduce or “carry forward” a complete physical exam, when in fact only parts of the complete examine were performed. The suggestion that some work was not done causes the entire record to be questioned, including the level of evaluation and management services billed. Remember, billing for services not rendered meets the definition of fraud.
Carriers have followed the lead of the Centers for Medicare and Medicaid Services (CMS) on the issue of cloning and cutting and pasting. If CMS finds that notes are cut and pasted or cloned it will withhold payment or, if necessary, take money back. The CMS position is that a duplicated note does not show that the work/care of the patient was done and therefore payment is not appropriate.
So, the time to change any bad habits is now. Write a note – a real note, telling what your assessment and plan is so other physicians can assist in the treatment of the patient. Physicians who click or carry forward words and phrases into a record whose motivation is only to get enough words down to satisfy an auditor are on notice. An improper effort to save time could be costly.