March 28, 2023 | By Shannon DeConda, CPC, CEMC, CEMA, CPMA, CRTT
With the adaptation of 2021 Guidelines and the reduction in documentation requirements, many coders and auditors had thought the use of copy and paste may begin to phase out. Unfortunately, this has not been the case, primarily because many providers are still not in full understanding of the new guideline requirements.
Recently, a long-time client who migrated to a new electronic health record system reached out with a new discovery. The unnamed system they purchased now had the ability to show them a copy-and-paste trail and whether the copy-and-paste was originally authored by another physician or non-physician provider. Never before had they realized the volume of copy and paste included per encounter, per patient. That was their first concern, which they were addressing internally. The second was the amount of copy and paste being used across physician-to-physician to provider, i.e., Clinical Plagiarism.
One of the lead physicians for the health system was in favor of creating a MACRO for all records that included copy and paste to safeguard them for compliance considering the copy and paste that could be included in the records. The request was made for third party review of the MACRO to ensure it was comprehensive in nature and fulfilled compliance requirements. The statement will be reviewed in this article, but first consider the guidelines for copy and paste, and what the known rules are related to the efficiencies of use with this electronic tool.
Guidance: Copy and paste is allowed when it is used according to the guidance set forth for best practices of electronic medical documentation. The “rules” or “guidelines” that pertain to copy and paste are pulled from various resources such as the Program Integrity Issues in Electronic Health Records: An Overview by CMS, and other payor guidance. The following are the requirements in bullet format:
- Copy and paste should be used as appropriate. The interpreted meaning of this statement is copy and paste should only be used as needed, it should be used with purpose, and with intent. In other words, the entirety of the note should not be compiled by copy and paste.
- Copy and paste should only include documentation/work that is the providers authentic previously recorded documentation. The use of copy and paste from someone other than their own work/documentation can be inferred as clinical plagiarism. This sounds like something from college days, but it also carries the same weight. Plagiarism is the act of citing someone else’s work and claiming it as your own. No matter how kindly the term ‘copy and paste’ is stated, often the intent behind copy and paste in medical documentation is with the purpose of satisfying the perceived documentation guidelines, which is in fact using someone else’s work as your own. Furthermore, 2021 Guidelines and the 2023 Expansion do not require the same level of intense documentation structure as did 1995/1997 making the need to borrow documentation extinct.
- Copy and paste of a peer’s documentation/work can be included when it includes the appropriate site source. Therefore, when a physician or non-physician qualified provider want to include relevant information from another in their own documentation, the information can be appropriately copy and pasted into the encounter, provided it is site and sourced.
It is important to not only consider the guidelines and what is published, but also what is not published as part of the guidelines. The guidelines do not include exact specifications that many would like to see incorprated. For example, the following are common nuances within copy and paste that are not addressed in published guidelines:
- Allowed percentage or volume of copy and paste documentation: Often in discrepancy is how much of the medical record a provider can actually copy and paste from another medical record and it be considered appropriate. There is no guideline or rule as to what level of copy and paste becomes inappropriate.
- Areas of documentation that should not be subject to copy and paste: There also is no rule that precludes area of documentation from being subject to the efficiencies of copy and paste. If the physician or non-physician provider feels its inclusion is relevant and includes the documentation according to the guidelines, any portion of documentation may be included by copy and paste.
- The scribe or medical assistant [can or cannot] copy and paste content on behalf of the provider. A physician or non-physician provider is able to use someone to assist in documenting the note on their behalf. Guidelines do not indicate that this would preclude the ability to copy and paste. The information should be reviewed to ensure accuracy, relevance, and its appropriateness for the encounter just as any non-clinically created documentation should.
As mentioned earlier, the guidelines were listed, reviewed and discussed in order to provide clarity of what is addressed as well as not addressed within them so as to better prepare ourselves for consideration of the MACRO for review. By way of a reminder, the request is to consider use of the following MACRO to accompany notes that include copy and paste. Below is the proposed MACRO:
Cut and paste and carry forward elements of this document were validated as accurate, relevant, and up to date for the purpose of today’s documentation. This content was reviewed as pertinent to care, and reflect today’s medical decision making.
Based on the guidelines reviewed, the MACRO is simply not needed. If copy and paste are used appropriately, then the statement is a moot point, and the content of the documentation should speak for itself. If copy and paste was not documented appropriately, inclusion of this MACRO confirms the physician and non-physician qualified provider performed the review of the documentation using copy and paste and to please scrutinize the note accordingly.
Other concerns are also raised from this statement. Consider the following:
- As stated, this client utilizes an electronic system that allows the auditor the ability “linger” over entries which then can identify if they were copy and paste. However, this organization, and any organization using a similar such electronic record system should keep in mind, this information is seen at that moment by the internal audit team, however a carrier audit only typically only sees each encounter note at a time. The “linger trail” could of course be discoverable through an extensive carrier audit, and for this reason, copy and paste should be used appropriately and rules regarding clinical plagiarism adhered to as well. The MACRO is calling awareness to the use of copy and paste needlessly in the encounter – which is not required nor necessary – and may not be evident otherwise.
- A MACRO does not always solve a documentation problem; at times it creates one, as noted above.
- This MACRO states the obvious as this is work that should be done for each encounter. For every encounter only the physician or non-physician provider should include information that has been reviewed, that is pertinent to care and reflects today’s medical decision making. Therefore, there is no need for the MACRO.
- Considering the above, what does this MACRO achieve in documentation? Potentially, this MACRO may not have a positive impact, but rather only negative. As noted above, this MACRO unfortunately provides no positive value to the medical record; if anything it only draws attention to points about the encounter that were best not in the spotlight.
Within 2021 Guidelines and the 2023 Expansion, there isn’t really a need for copy and paste except for a need to site and source information that may be recorded from another physician and non-physician qualified provider due to the integrity of the content. From time to time, a physician and non-physician qualified provider may read a description or history of a patient recorded by another provider and wish to memorialize the information in their record for future reference and use. This is of course when site and source of the content would be appropriate.
This information is not needed for a boost to the volume of documentation content, as the guidelines no longer have requirements for determinants of history or exam characteristics or prerequisites from previous encounters. Rather each encounter is solely based on the complexity of the presenting problem(s) and the risk of complications of patient management or treatment options considered during the encounter or the time of that specific encounter, and in the case of time-based services, the amount of time required should be authenticated per encounter as medically necessary. These elements do not necessitate copy and paste.
Copy and paste therefore, should be a function used for sourcing information as opposed to accumulating documentation.
When considering the use of a MACRO, consider the following steps first:
- Why is the information being copied into the record? If it is for informational use by the rendering provider, then the appropriate site/source should accompany the information insert. Using the previously discussed MACRO as the basis, consider the following example:
The following excerpt was noted [in the admit H&P]. This information includes relevant history and detailed information regarding the patient and has been included with this encounter for the rendering providers purposes. This content was reviewed as pertinent to today’s medical decision making.
- Is a MACRO needed? Meaning, is the information relevant and pertinent to the encounter? If there is no purpose for the additional content, such as noted above, is copy and paste necessary, and then also would a MACRO be necessary?
- It is important to advise clients of what is in their best interest for the sake of compliance, but also when it’s not a compliance risk, to meet the Client where they are. Therefore, if, after consideration of the above, the organization is still in favor of moving forward with the MACRO, the recommendation would be provided to revise the MACRO as follows:
Cut and paste and carry forward lements of this document were validated as accurate, relevant, and up-to-date for the purpose of today’s documentation. This content was reviewed as pertinent to care and reflect today’s medical decision making.
These recommendations are made based on best practices of use for Smart EMR/EHR Documentation Tools.
It is in our best interest as auditors and compliance professionals to work with our providers to use efficiencies to streamline the creation of documentation within the EMR. MACRO, Template, Copy/Paste offer these capabilities. It is incumbent on us to show the path to compliant AND effective and purposeful use.
Your next steps:
- Schedule a consultation for 2023 audit planning and a provider documentation review.
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
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