Cut & Paste: Medically Necessary Documentation—Or Clinical Plagiarism?

Event Information
Product Format
Prerecorded Event
Jill M. Young, CPC, CEDC, CIMC
60 minutes
Product Description

What’s Your Financial Exposure When You Cut and Paste Notes?

Electronic health records (EHR) arrived on the medical documentation scene with little regulatory guidance. And there’s still scant instruction on—but plenty of skepticism about—the practice of cutting and pasting (or “carrying forward”) health data from record to record. And yet so many medical facilities do this. Is yours doing it right?

A recent study in the Journal of the American Medical Association found that only a small minority of progress reports were manually entered, while more than 80 percent were imported or copied. The problem with cut/paste documentation practices is that you risk introducing outdated, inaccurate, and/or unnecessary information into what should be a concise, correct, and current reflection of a patient’s condition. The Centers for Medicare and Medicaid Services (CMS) is scrutinizing cut/paste practices, too—because “cloned” information can so easily be misused, it says.

Don’t get stuck supporting bad documentation habits in the name of speed and convenience. Join coding and billing expert Jill Young for a thorough examination of this problematic issue. She will teach you when cut/paste is an acceptable documentation tactic—and when it is decidedly not. Plus, she will explain the current industry thinking on the issue, including how a number of insurance companies and CMS view the practice.

After attending this event, you will be able to inform physicians of the current policy on the cut/paste documentation. And you’ll have the knowledge you need to decrease your practice’s financial exposure in the event that your charts are audited. Importantly, you’ll be set up for success if CMS comes knocking.

Session Highlights

This program will discuss:

  • The definition of cut and paste documentation
  • The definition of clinical plagiarism
  • What information is appropriate to cut and paste
  • Medícare’s rules on cut and paste
  • Other ínsurance carrier policies on cut and paste
  • How pre-populated templates are a cousin to cut and paste
  • What financial exposure you risk when notes are cut and pasted

Session Agenda

The session will cover useful topics, such as:

  • Cut, Copy & Paste Definitions
  • MCM Chapter 12 Section 30
  • Electronic health récord issues
  • Guidelines for copying and pasting medical records
  • Templates and trouble with prepopulated templates
  • Cloned documentation – CMS/Medícare
  • Denial for medical necessity (CGS)
  • Clinical plagiarism
  • Cloning
  • WPS Medícare policy
  • Review of Systems
  • Physícal exam
  • Document a representative exam
  • Copy-and-paste safety concerns

Who Should Attend

  • Providers such as physicians, NPs, PAs, and CSWs
  • Coders
  • Auditors
  • Office managers
  • Office administrators

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About Our Speaker

Jill M. Young - Pulmonology Guidelines Expert

Jill Young, CPC, CEDC, CIMC, is the Principal of Young Medical Consulting, LLC, A company founded 11 years ago to meet the education and compliance needs of physicians and their staff. Jill has over 30 years of medical experience working in all areas of the medical practice including clinical, billing and rounding with physicians. Her comments and opinions can be seen in several publications and also...   More Info
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