Electronic medical records revolutionized medical records.  As of 2021, 88% of physician offices had some form of computerized health records for their patients.  The astounding 50% increase in numbers 2008 statistics, was not without growing pains and compliance issues.  First cut and paste issues were identified with physicians not doing the work of documenting the services they performed.  There were early warnings to hospitals from CMS about this practice, but physicians did and still use and re-use information from chart documentation into the same chart and into other patient’s charting creating compliance issues.  Clinical plagiarism was the next identified issue with providers copying information from another provider and pasting that information into the patient’s chart.  The information was not identified as being from someone else, hence the name clinical plagiarism. 

Webinar Objectives

• What if any information are you allowed to bring into today’s note from a prior one? 
• CPT saw changes to Evaluation and Managements coding and documentation guidelines in 2021 and 2023.  Should this and could this decrease the volume content of your provider’s notes
• Are pre-populated text entries a problem?  When are they not?
• Why does the old system of documentation put you at more risk than the new? 
• Is the copying or cutting and pasting of text from a library of “normals” fraud?
• If the documentation from the Review of Systems is in conflict with other parts of the chart documentation, is that a problem?  What are the consequences?
• What information can be brought into a new date of service from an old note?
• How do the new E&M Guidelines for office make it easier to retrain physicians to create original documentation for their visits?

Webinar Agenda

• Creation of Electronic Medical Records (EMR) systems were created, what problems were there from the onset?
• What information is now required since the changes in 2021 and 2023 to E&M services?
• What is the difference between the old H&P and the new “medically appropriate history and exam”?
• What is meant by original work by the provider for a patient?
• What is new about medical decision making and its documentation to show support of the level of service billed for the service today. 
• How does a note meet medical necessity?
• What does your medical record software ALLOW providers to do? 

Webinar Highlights

• Where does medical necessity fit into this puzzle?
• With the major changes in E&M service requirements what “should’ current documentation in a patient’s record contain?  Tips on how to train this information to your providers
• Do your providers know what E&M visits in 2023 should look like?
• What to look for when reviewing a record when concerned about copied, cut & pasted or imported documentation to help you spot problems
• Coding issues (diagnosis and E&M) that arise from documentation that is cut & pasted
• A quick conversation about Split Shared visits

Who Should Attend?

Coders, Billers, Auditors, Physicians, Nurse Practitioners, Physician’s Assistants