It seems that everyone in the world of medicine is talking about the copy/paste problem in inpatient notes. Is it fair to call it a problem? That is probably debatable. In some ways, ‘copy/paste’ or the ‘copy forward’ that we use for our own notes, is one of the few things that the EMR has offered to make the physician’s life a tiny bit easier. In recent years, the EMR has not delivered on its promise to simplify our lives, quite the contrary. Tasks are added (especially to attending physicians) on almost a daily basis. Will this be just another task Medicare piles on?
The physician’s argument is that in some cases, nothing has changed from one day to the next. That does not mean care was not rendered, or that medical decisions were not made. But why alter a note if nothing changed? Where does the argument end?
The root of the debate seems to be around the risk the hospital and the provider are both taking if we bill for a patient encounter knowing it is copied from a previous note. I personally have seen a Medicare auditor print out two progress notes suspected of being identical, and hold one note on top of the other in front of a light. If everything appeared to line up perfectly, they demanded their money back for that encounter.
Their argument is that the note is the only visible product the physician produces and if it does not reflect a unique encounter for a given day, they won’t pay for that encounter! If a Medicare ‘probe audit’ reveals a copy/paste trend at our hospital, then a full audit (RAC led) will follow and any copy/paste would then require payback and fines from CMS. It’s a huge risk to the organization, and also to the individual provider….much more than it is a billing concern.
About a year ago, the Medical Executive Committee (MEC) adopted a copy/paste policy into the medical staff Rules and Regulations. You will find it on page 9. It reads as follows:
“While it is acceptable to copy and paste from a source document into the Salem Health EMR, the provider must adhere to the following:
A provider may not copy another provider’s document verbatim and use it as if it were their own work. If a document is copied and pasted, it must be stated as such and credit given to the author of the document. It cannot replace the provider’s own documentation for that encounter.
A provider may not copy forward or clone their own document unless the document is updated/edited to reflect the unique patient encounter for that given day.
If a copied and pasted or cloned document is unchanged/unedited so that it cannot be used for billing purposes, the document will be considered “incomplete” by the provider and a deficiency will be created in the medical record for that encounter.”
Please pay attention to the final sentence. As you can see, the decision as to whether a note is incomplete is based upon whether there is enough unique content to bill for the note. If there is not, the note is to be reassigned and has to be rewritten such that it can generate a bill.
With the recent EPIC upgrade, we now have the ability to easily screen notes for copied content, but we do not have clear guidelines as to what it takes to “reflect the unique patient encounter for (a) given day”. We do know that a note that is completely unchanged will not satisfy that requirement, so at this time, only those notes will be reassigned.
That being said, notes that are too similar are likely at risk of no payment by Medicare. Could this affect your own payment? That depends upon several factors:
1. If you are employed by the hospital, the hospital currently assumes the risk, but will need to mitigate that risk in some way in the near future.
2. If you are self-employed, you could be asked to pay those encounter charges back should Medicare audit that encounter.
3. If you are employed by another entity, you might want to inquire as to their specific policy.
We are aware of this risk, we do not wish to place undue burden upon our providers. It is our sincere hope that we might provide a solution that will satisfy the requirement for a unique encounter while making the work of the physician more efficient. That is a tall order. The take-home message for the moment is that only identical notes will be returned for edit. More to come on this topic!