Good day, my name is Jill Young, and I am here today to talk to you about your documentation. Big surprise. Something that you've been talked to before, but I wanted to talk to you at a different level. I wanted to talk to you from a perspective of exactly what it is that you're doing if you are cutting and pasting, using templates, duplicating information, and are you putting your practice at risk for being, if you will, against the rules and at risk during an audit? Now my rule of thumb, and maybe I should have put Jill's rule of thumb, or maybe put a thumb print up there, but I mean the rule of thumb is you should document what you do. And then from that, what is documented is coded, what is documented is coded, and then what is coded is billed, and you should get paid for what is billed. If you don't get paid for what is billed, then the question to be asked is should you have been paid for that in and of itself anyhow? And so I think we have to weigh that argument at times when I talk to physicians. When we look at the documentation of a patient's encounter, it should reflect that current condition of that patient at the time that they were seen, what other work was done that day, and then any other information, documentation, documents, if you will, that were included in today's note, that those are properly referenced so they can be brought into the note from an auditor's perspective. So let's look at these definitions of cut, copy, and paste, or copy-paste, cut-and-paste. I mean, we know if we use Word, you highlight and then you right-click, it is copy, and so you take it over to another document. Well when we look at a medical record, it is the same thing. You're in essence taking information and moving it from one area to another area. When we're looking on our electronic records, we are pushing information or pulling information from one source into another. So when we look at the words copy-paste, cut-and-paste, in some instances, cloning, again, it depends on what verbiage you're used to, pre-populated templates, those are copy and pasted into a document or pulled into a document. We have work that is pulled forward. A lot of electronic records are set up to pull information into the record, and that can be a problem if it's not something that you wanted to have pulled into the record. For example, the last 10 days of lab work on a hospital visit, or the last three visits of other testing that you need to address within the note because there were abnormalities. So pulling forward of information is included in all of this. And the biggest thing is, is we're not seeing original work that's documented. Now we know that the Medicare Carrier's Manual tells us that medical necessity is the overarching criteria for payment. Was it medically necessary to do something? Was it medically necessary to bring this information into the record that made it go to a higher level? Was it appropriate to bring that information? If a patient comes in with a hangnail, was it appropriate to do a comprehensive physical? Probably not, unless, of course, you find out that the patient has diabetes and hypertension, has already lost a couple of fingers and maybe a couple of toes to their disease process, and so that comprehensive physical might be warranted based on the documentation of your concern because of their health history, because of their prior health problems. And again, that all tells the story of the patient. So we have to always make sure we're telling the story of the patient, and as I say, we're making the sick patient sick. Medicare tells us that the volume of documentation should not be a primary influence. In other words, just because you have a five-page note doesn't mean it should be a level five and a four-page note be a level four. It's what is in the guts of the documentation, what is in the information contained. Because at the end of the day, if the documentation does not support the level of service in an audit, you're going to fail, there are going to be take-backs. And a very important part that I think goes by the wayside is that the documentation needs to be done as soon as it is practical to have it done. And so that doesn't mean that the documentation may not be put together and the physician doesn't sign off on it for a month, because that medical record isn't complete until the physician signs off. That means that medical record should not be billed until the record is complete. So until that sign-off takes place. So not just the documentation, but the completion of the record. All of this from a Medicare Carrier's Manual, which is sort of the gold standard that we use. So when we look at problems that come from cutting and pasting, and the fact that our electronic health records have been marketed to tell physicians, you should be cutting and pasting, it'll save you so much time, you can pull forward information, you don't have to re-document information. And so that pre-population of information that comes through may not be appropriate, or sometimes there are records that are pre-populated based on the type of service or the chief complaint, asking questions like we see on those T-notes from the emergency room, the old T-notes. So electronic health records, we have templates that have everything checked. We have no logic of the information. We have conflicting information. When the patient is filling out forms, making sure that they understand the forms that they are completing, have the information in a format that is usable, and we'll talk more about that in just a minute. Gathering information from a lot of different sources for this talk, you can see this is a university hospital's policy that says that copying information might be appropriate as long as we can tell that it's from another source. As long as we can tell that the physician pulled this information into the record with a purpose, identifies it as outside information, and perhaps indicates why they're bringing that information in, as opposed to just inserting it in the record without any history of where it came from. Indicating, as it says, copied information should be brief. Copied text and findings need to be integral and also show medical necessity. And then having this accurate description of treatment provided on a specific date. So just putting information into the record to show that the patient was seen without any relevant information for that patient's visit from that date of service is just not appropriate documentation. Now, we can certainly copy information, and again, this is this university's policy, that they say, okay, and I'm going to get a little pen here, it says information that may be copied under very rare circumstances. Physical exam descriptions from a previous day. Even that, for some of our carriers, you can use it in reference, but you have to indicate it was yesterday's work and not today's work. And if you need that physical exam for today's work, then that's not going to count. So we have to watch the information we're pulling forward. I know we like our dot phrases or smart phrases, and it's okay to use those phrases, but again, we have to make sure that the information in the note in total is unique for that patient for that date of service. Templates should not be, as it says, charting by exception, where everything is negative and so any positives are something that the text has to be changed. One of the things that I see as an auditor, as one of the most common mistakes, is where we have a history or a physical template that has all negatives, but the patient's chief complaint and the assessment and plan indicates that there was something wrong in a particular body area or body system that wasn't, if you will, unchecked or wasn't corrected in the record to indicate that, yes, the patient did have this in their review of systems, did have this on physical exam based on, again, other documentation in the record. So pulling the templates in is problematic in and of itself, but it also has been, in my experience, leads to one of the most common causes of conflict within a record, and anytime there's a conflict within the record, for me, that means that that record is going to be invalidated because of that conflict, showing that it wasn't unique documentation. Templates should be a reminder of questions to ask. They shouldn't have the answers already filled in, and the answers don't have to be extensive. Pertinent positives, pertinent negatives. So making sure that we have the appropriate information on there. When we look at our 2021 rules for office and other outpatient visits, that really changed everything that we do. The AMA changed our CPT book and said for office and other outpatient visits, we no longer are using that three system history, the history area, a physical exam, and then medical decision making, requiring three out of three for new patients and two out of three for established patients, but we're now going to only look at medical decision making or time. No longer does the history or physical, if you will, count. There's no points, if you will, because you're not really using a point system anymore. Now, is it still appropriate to do a history and physical? Yes, a clinically appropriate one. But that information documented into the record is only documented to show one was done. You don't have to bring a template of a normal female physical in. You can simply say, you did a complete physical on this female, and here are the pertinent positives and pertinent negatives. And so instead of a whole template being pulled in, now a very succinct statement, again, with the pertinent positives and negatives, that becomes appropriate documentation. And we really now focus in on the documentation that leads to the medical decision making. For 2023, if you haven't heard, our hospital and observation visits and then all of the rest of the visits, our nursing home visits and other location visits, they are all going to this same system. So in 2023, when you're working in the hospital, don't need that great big physical template to be pulled in or that big history to be pulled in. It's only going to be clinically appropriate. And that also means it has to be what you are comfortable with. If it's a new patient or an admin and you want to document a full history and physical on the patient, certainly you can do that. But understand that you don't have to do that, especially on those follow-up visits where you're trying to be expeditious with your time. CMS Medicare, when we talk about cloned documentation, said that it's worded exactly or similar to previous entries. And then it also says that it's cloned when it's the same for person to person. So if you have documentation that is cloned over based on the chief complaint, CMS is very specifically saying, nope, that's not appropriate. You're not supposed to do it that way. Our MAC contractors, which are the contractors that are regionally assigned to process your Medicare payments here in Michigan, we have WPS out of Wisconsin. Other MAC carriers, I'll quote that I did some research on them, but the MAC contractors have been directed by CMS, who they work for, to identify this suspected fraud. Because one of the things they're saying is, under the rules that are allowing for points for a history exam and medical decision making, if you're pulling in a big physical for a minor complaint, you're in essence setting the stage for upcoding. And so that's why they're considering it a problem and considering it fraud. And as it says, considering it a misrepresentation of the medical necessity of services. So we need to have, again, this individual information for that patient, for that date of service. CGS, which is another one of the Medicare MACs, it says medical necessity. We've already talked about that. And then it says necessity is considered fraudulent if cloning of past services and medical notes from previous days are simply reinserted into the new day's progress note to justify need. Now I know in the hospital, especially with hospitalists, a lot of them like their progress note to be a running history of the patient, if you will, so that if tomorrow a different physician sees that patient, they can quickly see what's been going on with the patient. And that is fine in another area. It cannot be the progress note of the patient that we're going to use for coding and billing. We need to be able to see where is today's note that is unique for this patient for this date of service and not see a bunch of old cut and pasted information that's being brought from other dates of service. The Office of Inspector General, or the OIG, certainly is looking at these duplication standards that we have in hospital charting. And again, as we've seen in other places, saying it may be associated with improper payments because of this over-documentation, documenting complete histories, complete physicals, taking the points and credit for that when it wasn't appropriate to do as much of a physical as was done based on that template being pulled in. The Office of Inspector General also warned HHS they've not really adequately addressed these concerns that the electronic health records has created. If you think about a paper record, are you going to photocopy a record from a previous date of service and then literally cut and tape it into today's record and call it original work? No, you wouldn't do that. You kind of can't do that. And so doing it with a computer record really is just as not a good idea as we see. There was a journal that I read, I'll show you the source in a moment, on electronic medical record cloning that says, you know what, if you're copying, pasting information from other physicians' notes, they are talking and calling it clinical plagiarism, that you're taking other notes. I see it in consultants' notes where one consultant will copy and paste the history and the physical exam of the patient from another consultant, from another physician. And although they may have done all the work and we're just lazy at documenting it, it doesn't matter. It's impossible to know if you have pulled in someone else's work, what exactly was the work that that provider did. When we look at what they call overwriting or cloning, it misrepresents who provided the service and therefore, you know, having that documentation not at the original content that it should be. So they are saying, you know, that is potentially upcoding or coding for services that weren't necessarily provided and they're looking and calling that insurance fraud. And there's a reference from where that article came from. Since electronic records have been in their infancy, positions on hospital committees should lead the development of standards for copy-paste. Certainly I have seen providers that will copy and paste a note in the progress area and then looking at that, write their new note. And so it's really just copy-pasted as a, like a sticky note, if you will, that they can reference. Certainly, as the second bullet says, you know, having that narrative and tailoring it to their own normal documentation, but we want to make sure that we're meeting that standard for original work on that patient on that date of service. Again, WPS is our policy. They say you can use templates and checklists and they are acceptable documentation, but they've got to be specific to the patient and the service in question. So it can't just be a generic male normal physical exam that you always use. There has to be some uniqueness for that patient, for that date of service. And again, as I mentioned, coming up with comprehensive levels of service in the history and exam area, just because you're pulling in a whole great big page or two or three of information is just not appropriate. And the insurance companies are now saying more and more, if this is what we're seeing, then we're going to reject it. They're not anymore asking for a singular date of service on a patient, they're asking for multiple dates of service on a patient so that they can make that comparison. Medicare, our Medicare carrier WPS says that if you have pertinent, abnormal, relevant negative findings that if you just say abnormal, if you don't elaborate on that, then that is considered insufficient documentation from their perspective. They have to describe what is abnormal and exactly what effect does that have for the patient. And as I mentioned, here's another example of the trouble with templates in a normal, in the GI system is marked from the template and yet there were problems that were there, but they did not get, if you will, cross-documented and so the chart ends up in conflict. And again, not only in conflict, but over-documented and potentially being accused of billing for a higher level of service than was appropriate. We know what the review of systems is, we know the best way to collect this information is to make sure that you have a form that is very exacting in the questions that it's asking. I always remember when my dad went to a doctor's visit and he was in his 80s and he said, I don't understand what you're asking on this review of systems form. And the girl said, well, you need to just mark if you've ever had any of those things. And he's like, I'm 80 years old. And so he just marked yes for everything, just made a great big long line down every single column. That's not the information the doctor's looking for and that's not a good collection of information. So not only do we have to make sure we're getting good information, sometimes we have to sort of help our patients to understand what is it that we're asking for. So I'm gonna briefly go over a little bit of the information that is changing when it comes to review of systems, history and physical exam, but I want to be sure, because we do still have time left in this year and I want to be sure that you understand why it is that this problem should go away because of the new E&M rules for office and other outpatient services, hospital observation services and then other E&M services. Because again, they're not going to require or give any credit for the history and the exam, but rather simply requiring pertinent positive. So we know that our review of systems has three levels. So I'm gonna get my little thing here and the problem pertinent and extended and then a complete review of systems. And again, remember the review of systems is supposed to be about systems directly related to the problem. That's why the great big review of system sheet that's filled out has to be asked appropriately of the patient to collect the information that is needed. So if we have this complete review of systems, making sure that we do have appropriate positive, pertinent positive and pertinent negative responses, you are allowed to say all other systems are negative and then you're not documenting a whole lot of information that can be conflicting. You're not inserting a whole great big template of a review of systems, but rather simply documenting pertinent positives, pertinent negatives. And looking at the rules, you only really need two systems for established patients in the hospital. And so why document eight or 10 when two will do? Now, if you want to document five or six, because that's the information that's important to you, that's fine. I'm not saying you can't do that. I'm simply saying, here's the minimum standards. Let's go with the minimum standards at times. We see in the 1995 guidelines, it did say the extent of exams performed to document is dependent on the clinical judgment and the nature of the presenting problem. So in some ways it hasn't changed, you know, what's an appropriate, what's a clinically appropriate physical exam. So when we look at this structured templates, if you will, or this, you know, charting by exceptions, rather than have all of this information, sometimes very verbose information that you have to remember to go in and uncheck anything, why not go down to the statement, here's the pertinent positives and negatives, and then all other systems are negative. The same is true with an exam. When you're doing an exam, if you say eyes, ears, nose, and throat are normal, and don't put all this information, because what has been my experience is that if I see this in the chart record, and this is straight from the 1997 guidelines, then I'm going to question and look for, is there any conflicting information in the record because there's such specific information that, you know, they looked in the oropharynx, oral mucosa, salivary glands, hardened soft palates, tongue, tonsils. You know, I find out the patients had their tonsils taken out, oops, you know, there goes that conflicting documentation in the record, because that statement is here, and that statement's always going to be challenged by the patient's history. And again, just looking at some significant documentation, pre-populated templates. If any of yours, I love this one for the eyes, that's huge, which if perhaps you're an ophthalmologist, that would be appropriate. But if you're just a, you know, primary care doctor, why are you putting all this information in? Keep it simple. You know, what's the abnormalities? What's the pertinent positives, pertinent negatives? Doing this representative exam. And again, this is under the old rules, but we can also carry it forward to the new rules to say what is pertinent and positive, what is clinically appropriate to do in this exam? If we're looking in the hospital, documenting what is pertinent to the patient today, what is appropriate for today's problem, what is appropriate to the level of service that is being billed today? And only the clinician can answer what is appropriate. You know, when we look at what is the clinician thinking, what is the provider thinking, writing down that they have some suspicions about this, and that's why they're doing more testing, that's why they're doing a greater exam, that's why they're fill in the blank, telling the story of the patient, justifies going on. And pulling information in just to pull it in does not show that work. It doesn't give any insight into the motivation that the provider had in what they were doing. So again, looking at old rules, documenting an exam as would be appropriate under the old rules, keeping the information succinct, don't need to bring in that whole normal female physical, or even pull in information, copy and paste it from yesterday. So we look at the CPT information for office and other outpatient E&M services. And I put this in this lecture because this was a change that occurred in January 1st of 2021, where I've mentioned before where the history and exam only need to be done medically or clinically appropriate when it's performed. And as they look at this information, and there's certainly pieces that the care team can collect, it's not an element in the selection. And as I said, you don't get credit for it. And so that information just isn't pertinent. We don't need that whole great big section. Just a reminder that the 99201 was deleted. We see that because once we take away the history and the exam portion, the medical decision-making was straightforward for both of those codes. So that code went away, that code for a level one new patient, which I'll bet most of you have never used. So in 2021, we have this medically appropriate when it's performed, when it's medically necessary. And again, those are telling the stories of the patient. So when we look at what was finalized in the 2019 final rule to be effective in 2021, it says, okay, in order for you to look at, CMS is saying in order for you to look at how are you going to choose the level of service, it can be based on medical decision-making or it can be based on time. And so these levels two through five of both our new patients and established patients, we have this medical decision-making or the total time personally spent by that reporting practitioner on that date of service, time that does not have to be continuous. It includes time that is both face-to-face and non-face-to-face. And CMS did this believing that this would help to reduce as they call it administrative burden. And as Dr. Peter Holliman, who has been one of the physicians along with Dr. Levy that has worked on this for the last five or six years, basically trying to get back to document the work that you did in a succinct way that allows for the next physician to know what was going on without having 20 pages of a record that don't really tell me what happened since the last visit. When we look at this medical decision-making for 2021 for our office and other outpatient services, it AMA tells us, and you can see my references down here in the bottom corner, the AMA tells us that it's about establishing a diagnosis, assessing the status of a condition and then selecting the appropriate management options. Now, when we look at 2023, the entire classification of E&M services and the subcategories in the CPT book is changing. And one of the handouts that you're gonna have is in essence, a PDF version of the front of a CPT book. The nice thing is you're gonna be able to see any changes that have taken place in the guidelines because they're gonna be in green ink. So as you can see here in these subcategories, new and established patients, that definition hasn't changed, but initial and subsequent services has had some change to its text. History and or exam has had information change within its text. And again, this is for 2023 and this is for the entire section. So as we're talking about cloning and cutting and pasting, we have to look at what are the new guidelines? What is it that we need to adjust our thinking to? So as we look at these guidelines, selecting the level of service based on the medical decision-making, what kind of elements are included? Notice this is green ink, meaning this section has new text. We know that the number and complexity of problems addressed at the encounter, that hasn't changed because it doesn't have the green text, but some of the other things have. And if you've gotten good at your office and other outpatient services and the changes from 2021, then you're gonna be in pretty good shape as we look forward to the changes that are coming for hospital and observation services and various locations for 2023. So what does this do? Well, as we look at some of these different sources, and this is from the National Institute of Standards and Technology, that says, you know, short cutting and pasting information can jeopardize patient safety. And there have been, you know, articles written of instances where notes were cut and pasted and there was, you know, little pieces of information within a progress note. For example, there was one that I always remember that said that the patient's blood sugars were still elevated and doctors for two days without looking at the lab tests, looked at that note, saw that they said the sugars were elevated and were giving the patient medication. And the patient had a problem with the medication that they were being given, the insulin that they were being given because their sugars were fine. But because that progress note had been cut and pasted with that little snippet of information in it, they were acting based on that and acting inappropriately. There was another case where the patient was extubated and that note was carried forward by a couple of different people. And when I audited the record, the patient was extubated three times in one day because PT period, EXT, patient extubated, was copied and pasted within the confines of several sentences and no one noticed it. And that made that note read that the patient had been extubated three different times on the same day, which was not true, but that was what was in the documentation. So when we look at the new rules for documentation and what we don't have to have, the cutting and pasting problem seems to be something that can go away just through application of the rules. You know, as the National Institute of Standards and Technology says, you know, it's hard to figure out what is going on with the patient when you have so much information that is being carried forward or cut and pasted. Now, we know there are some softwares that do differentiate when you have cut and pasted material, but to have to hover over it and watch it change colors, you know, if you're going to use someone else's documentation or use documentation from a prior date, it should be referenced as such so that it would be obvious and not look like it's original work. Again, medical necessity says we have to do original work, document the original work that was done on this date of service for this patient. We hear the phrase note bloat, very aware of it that especially happens when we have pre-populated texts coming in, lab tests coming in. You know, again, not only audit concerns but patient safety concerns. You know, if you have pre-populated lab work, or I'm sorry, if the lab work is pre-populated into your note and there's an abnormality in the lab and you missed it and you sign off on that note, you signed off on not doing anything about that abnormality and that certainly has implications both medical and legal. So as we look at this copy paste function, you know, I don't understand why it ever got turned on. I mean, I guess I do, but it's almost like it has such a negative impact. I think it is something, it is sort of a switch on a computer that can be turned off by someone at some level, but we want to be sure that the information, if it is going to be pulled into a record or copy and pasted, that it's easily identifiable, that it's not something that, as I said, I know in the one software, you have to hover over something and it changes color and now you know that was copied from somewhere. You know, making sure that staff are appropriate in their use of copy paste, making sure that the notes are appropriate, that regulations, rules, and guidelines that any hospital or office has regarding the copy and pasting of information are followed. There was a study done at UCSF and it said that clinicians copy and pasted nearly half of their electronic health record progress notes. They reviewed over 23,000 records. More than 80% of the text was either carried over or imported by physicians. That's a crazy amount. When we look at they manually entered only 18% of the text, a bunch of it was copied, a bunch of it was imported, and this was according to some results published in JAMA. This was a couple of years ago. There's a more recent study we're going to talk about in just a minute, but making sure that we have this information, residents entering only 12% of the text with greater than 46% copied. Hospitalists only entered 14% of the tasks. Priority Health, which is an insurance here in Michigan, talks about defining cloned. And it says, here's how we define cloned and in another place it's going to say, well, we don't consider this appropriate documentation. Noridian, one of our Medicare carriers, says cloned documentation does not meet medical necessity. And so they're going to recoup any overpayments when they find cloned text. CGS and Palmetto, again, Medicare contractors. It says the link between electronic records and billing are going to have problems with medical necessity. Identification of this type of documentation will lead to denial of services. This is the same kind of statements we see from Aetna and Cigna and many of our other carriers. So if we have entries in the medical record that are exactly like previous entries, we're going to talk in a minute about a couple of specific cases. We want to make sure that you realize if an auditor is looking at this, they're going to say, well, the patient can't be presenting exactly the same either day after day or visit after visit when there's time in between. There has to be something reasonably different. There has to be something that would have and meet those requirements of the unique documentation for that patient for that same date of service. Because at the end of the day, what we saw in all of those slides is that cloned documentation can certainly lead to a denial of service and a recoupment of payment. Now, Priority Health, again, says doesn't have specificity, doesn't have medical necessity. It's a falsification of a record and that they're not going to make payments for it. When we look at, you know, cloning, copying information, it's maybe time-saving and meets requirements for documentation. But if records are compared day to day, it does not meet documentation requirements. And again, this is an EHR intelligence article talking about its grounds for fraud and abuse. So, Medicare contractors have looked at electronic records, they've looked at state regulators, they've looked at these template-generated records. Not appropriate to have that kind of documentation. And the contractors say on many of their websites that clone is a misrepresentation of the medical necessity requirement for coverage due to the lack of specific information you need to the patient. So that, if you haven't heard those words, you need information you need to that patient for that date of service for that patient. So, they're not going to pay these if they see it. NGS specifically says they're not going to pay it, others imply it. If we look back at the integrity of medical records, look at this, this is from 2014 and 2013, going way, way back and saying, where are the safeguards that we have in our electronic health record technology? And again, must be specific to the patient. I think that's the most important takeaway that you have because we're upcoding, we have pertinent negative findings that are noted that are appropriate or aren't appropriate. And again, looking at specifics for some of the carriers, that's where we're getting this information. Now, the Joint Commission Journal on Quality and Patient Safety, they said, okay, you know what? We're going to make four recommendations. So, make sure that we can identify this copy pasted information, make sure that the provenance of this information is available. Make sure that staff training and education about it is available and appropriately used, and then monitor practices. Make sure that people are following the rules. So, those four recommendations, along with another recommendation that just says, you know what? We need to make sure that we're using the appropriate tools, using the appropriate workflow steps in order to have the best documentation that we can have. Because at the end of the day, when we look at the information that we have, this is from the Electronic Health Records Provider Journal, you know, author identification, different providers can add to the same progress notes, but we need to be able to know who's making that entry. We can make addendums, but we have to make sure that there's a reason and that the addendums are appropriately made. You should not be able to go back into a medical record that's electronic and make changes. You would have to put an additional note changing that information. Again, from this Electronic Health Record Provider Journal, when we talk about cloning and they're issuing words of caution and saying how it can be misused. Medical record must contain documentation showing the differences in the needs of the patient for each visitor encounter. So a unique note for the patient for that date of service. And then again, reference to that 2013 OIG work plan. Also talking about upcoding, as they call it code creeps because you have all of this information. And again, that's going to go away when we talk about the new hospital and observation service codes that are effective in 2023. Now this letter is from 2012 and it talks about from the very beginning, false documentation. It talks about cloning. It talks about that it can lead to up coding. It talks about a patient's care information must be verified individually. It cannot be cut and pasted from a different record of the patient, which risks medical errors. So this is a letter from CMS to the American Hospital Association, American Academic Health Centers, a whole bunch of very powerful organizations. Again, dated 2012. So 10 years ago when electronic records were just first coming out and saying this is fraud to do this. It wasn't sent to the providers. It wasn't sent to the provider organizations. It was sent to the hospital associations. Always found that very interesting saying they're going to continue to escalate their efforts to prevent fraud and pursue it aggressively saying, we're not going to say that this is appropriate. And this was when Kathleen Sebelius was secretary of HHS. So CMS, it says cutting and pasting or cloning is a problem. It says there are some legitimate uses of cutting and pasting, but there are a lot of inappropriate or illegitimate uses of cutting and pasting. And so bringing any information into a chart record from another source needs to be documented where it came from and why it's being brought into the record or being integrated into the record and not just put in there as if it was new work. There was a article that was in JAMA just in September called prevalence and sources of duplicate information in the electronic medical record. Now, this is a very technical study where they looked at words and keystrokes, but they looked at over a million notes from nearly 2 million patients. I'm sorry, 100 million notes from 2 million patients. Gotta get those numbers. They're huge. And they found that 50% of the total text was duplicated from prior text from the same patient, 50% of a record. And then the duplication in text has been going up over the years, increasing in five years from 33 to 54%. And then that 54% came from text written by the same author, but there was also text that was duplicated from a different author that again, was copy and pasted into the record. So what they said was, well, you know what? You know, that just cast doubt on the whole record. You know, we're just not sure what's going on day to day with patient. And so in their comments, they say, you know what? This is hazard. We need to identify what to do, but we also need to, if you will, go back to our analysis to say, if we tell them to just turn cut and paste off, is that the best thing to do? Or is that going to create its own paradigm, its own problem? Now, I do recommend turning off cut and paste. You know, the provider has to remember that when they sign their record, they're validating their record, they're validating the information in the record is correct as documented and identified. If they have cut and pasted text or cloned text that's pulled into the record, that's wrong. They just validated that that was correct information. And so that creates a problem. When you're cutting and pasting someone else's work, it exponentially creates a problem. So any kind of interface, we have to make sure that we can not create a chart that's going to be flagged for fraud, that the chart is not going to be flagged for having too many pre-populated templates or too many cloned records or too many copy and pasted phrases. So when we look at, for example, a note, and this was something I was asked to kind of talk about briefly. And I think that if we use the phrase medical necessity, if we see a patient that's coming in for an office visit and then maybe an OMT, and maybe to you, the provider, it's the same old, same old, but again, we have to have a note that's unique to that problem for that patient for that date of service. And in doing so, because we're combining an office visit with a procedure, we also have to show the medical necessity for the treatment plan that we have. So what's the problem of the patient specific to this date of service, specific to this patient? And why is it we're recommending OMT? How did they do the last time? You know, the patient presents today with pain in the blank region. Last time the patient was here, we did OMT on the area and they felt that it increased the pain, decreased the pain. It got better after a certain amount of time. You know, sort of show what was done. There was a benefit of the service. That's why we're going to repeat the service. If the main reason for the visit is just to have OMT, then really an office visit isn't appropriate. You've already made the decision that OMT is what you're going to do. So doing an office visit to document what you decided at the last visit, it isn't appropriate to build that office visit. It is appropriate when you have the patient come back in to reevaluate them, to see how are they doing, and document as such to say, okay, we need to go ahead and, you know, do what we did last time and see if they continue to have benefit of it. But again, you have to have a note that supports in and of itself, the office visit level, and then lead that note into the progress of the procedure note for the OMT. And most of this is going to be free texted. Cutting and pasting the last note, pulling it forward, you know, saying patient has problems with their neck, blah, blah, blah, so we're doing this. That's not unique to the patient for that date. The patient continues to have problems with their neck. The patient continues to get better with the problems from their neck. You know, whatever, making sure you're telling the story of the patient and updating their condition on that date, and then indicating why it is we're going to give this treatment that we're going to give. So overall, if we look at the changes that we're going to see for 2023, the note is a totally different note. We're going to have the presenting problem of the patient tell the story of the patient. Note any severity or instability or involvement of other body systems in what you're doing. Don't just pull information forward. We're going to document a clinically appropriate history and physical, and that could be documenting in a group, saying the history and physical on the exam, the history of physical exam on this patient were performed, and here's the pertinent positives and negatives that I feel I want to have in my record. But you don't have to bring in two or three different templates to accomplish that. And now we can concentrate on the medical decision-making. What are we doing? What decisions did we make? What considerations did we have? What discussions did we have? With the new, I'm sorry, with the 2021 office and other outpatient services and the new 2023 hospital and observation services and other E&M services, that medical decision-making piece or time, that medical decision-making piece is how we're determining the level of service. So if you document your sick patients as sick, coming in the door, the nature of the presenting problem, and any of the stuff that goes in the beginning, if you will, of the note to show where is this patient in their care, in their treatment plan, and then what is it we're going to do about it, you're going to meet those requirements in a narrative. And I know that sounds kind of crazy because we've gone so far with medical records and having point and shoot, I call it, where you click on things and stuff comes in or dropdowns happen. You just need to have a short narrative on the patient. Like I said in the last one, Jill is here today for a follow-up on her diabetes. She continues to have struggles with maintaining her sugars at a particular level. I have recommended she do this. I'm going to refill her medicines. I'm going to see her back in four weeks. That's a note, that's it. That's all you need. And that could be a three, it could be a four, depending on the wording of the note. So when we talk about cutting and pasting, when we talk about clinical plagiarism, I think that if you can do the documentation according to the regulations, again, hospital and observation services will happen at the beginning of 2023. Office and other outpatient services are already in place where medical decision-making is the way we select the level of service. Cutting and pasting just goes out the window. You don't need to have that information. So all it's doing is putting your practice at risk, that you're going to be cited for cloning records, that you're going to be cited for pulling in pre-populated templates, that you're going to be cited for cutting and pasting work from another source or from the patient's own notes. Why take the chance? Now, electronic health records aren't going to like me for saying you want a free text, and it leads to some problems in some areas of data collection. But at the end of the day, there was a study done by the AMA on the new office and other outpatient services, and they found that the average physician could save a certain amount of time per chart. And they extrapolated it out, and it came out to 20 hours in a year that they would save. 20 hours is several workdays that you would save during the course of a year if you went to text that was more succinct, text that isn't just a bunch of, as we call it, blah, blah, blah, because you pulled a bunch of stuff from notes and put it in today's work. Just tell me what happened today. Short phrases, succinct phrases, unique phrases for the patient for this date of service, and then you're going to have that information. So there won't be any need to cut and paste. Again, no need to clone, no need to pull templates in. I want you to look at that information. As I said, in addition to the handouts, you're going to get a file that is, in essence, the pages of information from the front of a CPT book for 2023. Your office should always have a new code book, but if you don't do it any other year, please do it this year. But this is just so you can have something printed off in a packet information and look at what is their definition of an acute problem versus a stable problem of a problem affecting another body system so that you'll know what you need to document and documenting succinctly, documenting through free texting so that your notes are short and sweet to the point and yet very compliant notes. That's the important part. Cutting and pasting, pulling all that information in isn't necessary, especially in 2023 for hospital and observation services. And so let's just kind of get rid of it. Again, hospital and observation services and all the other E&Ms other than office and other outpatient services, those will all change January 1st of 2023. And that's the document that I'm sending you that talks about those changes, but it still has the changes for office and other outpatient services for 2021 in there as well. If you have any questions, there's a multitude of resources available to you that you can find on numerous websites and that the AOA has for you. And with that, I'm going to say we don't have any questions to work with because this is prerecorded. But if you do have questions, please don't be afraid to send them through to our host for today. They can forward them to me and I can see if I can get them answered for you. And with that, I say thank you very much for your time. And I hope that this has been helpful for you. And again, the changes to hospital and observation services is coming January 1st of 2023. Office and other outpatient services already changed last year in January of 21. So with that information, again, thank you so much. Have a great day.

medical documentation

electronic health records

improper billing

fraud prevention

Medicare standards

medical necessity

documentation guidelines

original narratives

compliance