Clinical Plagiarism Vs. Compliant Copy/Cut & Paste

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

What Insurers Say about Copy & Paste Documentation


Is copying and pasting text in a patient’s medical record ever allowed? What about the use of pre-populated templates like “normal female physical” – is this acceptable documentation? Or will cutting/copying and pasting in medical records always lead to failed chart audits and fraud flags?

Find out all this and more in the information-packed webinar by healthcare compliance expert Jill Young. Find out which software and hospital system got into hot water after a study revealed that only 15 percent of text was entered manually and not cut/copied and pasted. Learn what the Centers for Medicare & Medicaid Services (CMS) and other insurers have to say about so-called “clinical plagiarism” and why they think it can lead to fraudulent behaviors like upcoding.

After attending this in-depth session, you’ll know when you can – and cannot – “reuse” parts of a patient’s chart record. You’ll walk away with tips and insights on how to stay compliant and avoid creating red flags for fraudulent billing. Also, you’ll know what phrases to look for when auditing to allow your staff to audit and train their providers in proper, compliant use of copy/cut and paste.

In this program, you will learn to:

  • Spot what current documentation in a patient’s record should contain;
  • Identify red flags to look for concerning copied/cut and pasted or imported documentation;
  • Understand coding issues (diagnoses and E/M) that arise from documentation that’s copied/cut and pasted;
  • Beware of the current CMS, HHS Office of Inspector General (OIG), and other federal agency position papers and policies on “clinical plagiarism;” and
  • Locate information from your local carriers as well.

Who Should Attend:

This program is designed for coders, billers, auditors, office managers, office administrators, Nurse Practitioners, Physician Assistants, and physicians.

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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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