Worried about audits due to EMR copy and paste? There’s been quite a bit in the news about it lately—but the good news is that using some best practices, you can avoid problems.One of the recent articles on this was published in Medical Economics, which stated that “Cloning notes in electronic health records (EHRs) has drawn criticism from a top government report, calling the practice fraud.”
According to the article, the OIG is focusing on the copy-and-paste function used in most EHR systems that allows the person using the EHR to duplicate information across different records. The OIG went on to say that “…inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.” Also, the OIG blamed EHRs that auto-populate fields for “suggesting the practitioner performed more comprehensive services than were actually rendered.”
The OIG’s focus on EHRs is not surprising given the reported increase in upcoding and other inappropriate billing practices.
But EHR vendor HealthFusion pointed out in a recent blog post that just as Quickbooks doesn’t cause embezzlement, EHRs don’t cause Medicare fraud.
But they go on to say that there are certain steps your practice can and should take to avoid unintentional fraud. These include:
• Use cut and paste appropriately
• Use dictation to speed entries and ensure accuracy
• Review and update every note
• Every encounter is not the same therefore every note should not be either
• Set guidelines in your practice for use of cut and paste
Detect and Avoid Inappropriate Use of EMRs with Safeguards
Another important step cited in the blog post is to regularly generate a CPT frequency report. This fairly common practice management system report shows how many times each billing provider uses each CPT code. In the MediTouch system this report is available in the dashboard reporting section of the reports module, according to HealthFusion. The report allows your practice to compare the frequency of use of common evaluation and management codes with a widely accepted Medicare bell curve. In addition, it is wise to compare your practice’s trends to normal use for your specialty, information which is usually available from your specialty society.
Also, establishing guidelines for your practice can help you avoid inappropriate use of an EMR. Problem behaviors to be avoided include:
• Copying problems that are no longer active
• Copying medications that are no longer current
• Upcoding
• Not identifying author
MediTouch EHR gives providers help to ensure they are coding and billing appropriately, including:
• Tools to help you select the appropriate level of E&M coding to reflect the level of difficulty and time spent for the encounter
• Reporting options that allow you to track your percentages for each E&M code and compare to your peers
• Grand Central option allows you to accurately tailor the imported older record with current treatment plan, history, physical exam and more
Plus, MediTouch’s design makes all of this fast and easy on the iPad, so that you can complete your coding before leaving the exam room. This ensures that the encounter is fresh in your mind and you can record it most accurately. HealthFusion’s motto: “No homework.”
As Dr. Kevin Campbell wrote on his blog, “No physician wants to continually take a practice laptop home in order to finish entering EMR notes during family time night after night.”
Copy and paste functions are now widely available and commonly used in other software that physicians use, such as MS Word and Excel, many argue. Expecting them to stop using these functions in an EMR is not realistic. Seventy-four to 90 percent of physicians use the copy/paste function in their EMRs, and between 20 to 78 percent of physician notes are copied text, according to a September AHIMA report. In fact, a survey(1) cited in a recent AHIMA article noted that 80% of respondents wanted to continue to use Copy/Paste Functionality.
Diana Warner, director at AHIMA, gave some of the best advice on using copy and paste in EMRs at the 2013 October MGMA annual conference in San Diego when she reminded her audience that copying and pasting patient information has a place in healthcare, if used correctly.
Says Warner: "Copy and pasting can be used appropriately, if you have the correct policies and procedures in place. If you are pulling information, look at it."
