5 Tips for CMS Compliant Copy and Paste in EHRKnow how Physician can keep your EHR as per CMS compliance for healthcare.
5 Tips for Compliant Copy and Paste
Like most healthcare professionals, you’re short on time. That’s no surprise, since many practices must see more patients than ever just to stay afloat. That increased patient volume, plus burdensome documentation requirements, make it tempting to look for shortcuts. One of those shortcuts is the compliant copy and paste feature of your EHR. Use it sparingly, and you’ll save time. But use it too much, or in the wrong ways, and you’re putting your practice at risk of claims denials, inaccurate patient records, and even an audit.
When and When Not to Copy and Paste
Copy and paste, also referred to as copy forward, cut and paste, and note cloning, is the practice or reusing text from one patient record in another patient record (typically the same patient but a subsequent visit). Historical patient data (like family history, allergies, and surgical history) isn’t likely to change, so it’s usually not a big deal when providers transfer this information from a previous visit to the current one. It saves time and allows for increased face-to-face patient interactions.
The problem occurs when a provider copies visit-specific data from one visit to another. This can result in multiple types of errors. For example:
- If a procedure was performed on a previous visit, and the note was copied, it could look like the procedure was performed again at the current visit. The entire claim could be denied because there’s no medical necessity for the repeated treatment. You’ll have to spend expensive staff time re-filing the claim to get paid for any other services listed.
- Critical data could get lost in lengthy, copied sections. This is called note bloat—there’s too much information that’s not relevant to the current exam, so the chances of physician error increase. Missed diagnosis, adverse medication interactions, and poor physician decision making could all have disastrous effects for a patient.
- Copying notes from a prior visit could lead to upcoding—coding a visit as more complex than it actually is (for example, a higher-level E/M code, or billing for a diagnostic test that didn’t occur). This is fraud and also a violation of the False Claims Act. Even if you aren’t subject to additional penalties, you’ll still have to return any overpayments you received.
How to Copy Paste Responsibly
Most physicians and staff feel that documenting in the EHR decreases their productivity and takes valuable time away from patients. So it’s not realistic to expect providers to give up the copy and paste feature completely. Instead, follow these tips to copy and paste responsibly, not recklessly.
- Carefully double check the notes you’ve transferred and be sure that the information is both correct and relevant to the current visit. Remove any extraneous information.
- Envision each patient visit as a separate record. Each visit’s notes should stand on their own merit. If you cut and paste, take a little extra time to tweak any words or phrases to make the note visit-specific.
- Work with your vendor to make copied information easily identifiable. Your EHR could display copied text in italics or a different color, for example. Another option would be for copied text appear in a split screen to avoid cluttering the current note.
- Lock certain areas of the note to prevent them from being copied (for example, the signature field).
- Work with your vendor to create a way to track the origins of copied information. For example, have some way to identify the original source, track authors of the copied text, or create a log that tracks what was copied, when, and by whom.