Q&A for Webinar: Copy, Paste, and Cloning: Rules vs. Opinions
Here is a list of questions we were not able to cover in today's NAMAS webinar. If you have questions regarding your submission and would like to speak with us further about it, please email the webinar moderator directly for more information. (I'm not posting the email here due to spam issues, I apologize!)
1) How do I count a DX in a follow up visit when there is no change in the wording in the assessment and plan? For example change in med for HTN but cholesterol stable. Next visit (in a week) HTN better and cholesterol stable. For the second visits one or two DX?
Since it sounds like you are an internal auditor- I would first suggest knowing what’s really happening with your EMR. Are the diagnoses a carry forward to each visit? If yes, then I would query the physician and ask was the cholesterol addressed with the patient, or just listed as an active problem during this encounter. I would emphasize that if it was addressed with the patient, then the documentation would really need to reflect it in order for us to count it.
2) If exam template has been copied in from another visit during rooming and the provider makes no changes, would you count it? The provider's argument is "I signed the note" therefore I take responsibility.
Well, it sounds like you have done all you can do, but the true question lies in, was the exam… as documented performed on each encounter. NOW, it’s NOT our place to challenge the work the provider states that he has done, but the reason I mention it is- if he truly did- and he performed an exam on the same organ systems and the patient was unchanged/stable--- odds are the exam would be the same.
3) Med Onc Providers routinely push back about seeing the patients prior to all infusions and on EPIC "pull forward" in multiple sections (from the NAMAS conference I did get a large sigh from the crowd when i mentioned EPIC) our point back to the Providers has been as you state patient centric and "Provider what issues are you managing and making decisions on today whether chemo or non chemo related?" this is your level of work that needs to be supported in your documentation---AGREED? Do you feel this policy should be HIM, Compliance, Coding or enterprise? Having issue with ownership and admin sponsorship...
A better way to help your provider might be to discuss this with them in a bit of a different approach. Think of this like a subsequent inpatient follow up visit--- those patient probably haven’t changed since the provider just saw them yesterday and many are in a quandry as to what to document… well guidance tells us it is an interval level history—which means how is the patient since the last time you saw them. That’s what they should be documenting. Patient returns today since her last visit she has….. she has been feeling….. she feels pretty stable…. Severity, etc….
Maybe relating it this way may help. I think the policy should belong to Compliance and/or HIM- my personal opinion
4) What about sub-specialists who treat the same disease(s) for multiple patients who say that the exam approach and elements examined are standard for the disease and do not differ much from patient to patient or visit to visit? How does CMS view these situations?
You must remember that CMS does NOT provide guidance as those granular levels we would like. What I can tell you is they state the provider should document the exam that they performed. I would encourage your provider that a carrier auditor who saw his exams the same from patient to patient and visit to visit- it may stimulate additional audits or records reviews. But “technically” he is doing nothing wrong- provided he is documenting the exam he performed.
5) Physician questioning if he directs his scribe to copy/paste an HPI or components of an HPI from a previous note and tells her to make specific updates or updates himself for the current date of service do you count this as a current HPI? or would you allow the prior HPI to be copy/pasted by the scribe as Past Medical History? or no credit at all? He indicated he would also make the following attestation, “the scribe, under my direction, brought forward portions of my previously documented history pertinent to my conversation with the patient today”.
This is a tricky one--- you see the HPI is the work of the provider. And while a scribe may document it on behalf of the provider, in this instance IF he is literally telling her what to copy/paste- then, ehhhh…. Ok, but based on your comments it almost sounds like he is also documenting an additional HPI—so I’m not sure you need to count this as anything. Email me more if you like.
PS- the purpose of a scribe is to act like a transcriptionist--- sooooo, if he could speak it and she writes it- seems he shouldn’t need copy/paste…. Just saying.
These questions have been submitted by webinar attendees and answered directly by the webinar presenter, Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT
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