What Insurers Say about Copy & Paste Documentation

Are copying and pasting text in a patient’s medical record ever allowed? What about the use of pre-populated templates like “normal female physical” – is this acceptable documentation? Or will cutting/copying and pasting in medical records always lead to failed chart audits and fraud flags?

Find out all this and more in the information-packed webinar by healthcare compliance expert Jill Young. Find out which software and hospital system got into hot water after a study revealed that only 15 percent of the text was entered manually and not cut/copied and pasted. Learn what the Centers for Medicare & Medicaid Services (CMS) and other insurers have to say about so-called “clinical plagiarism” and why they think it can lead to fraudulent behaviors like upcoding.

After attending this in-depth session, you’ll know when you can – and cannot – “reuse” parts of a patient’s chart record. You’ll walk away with tips and insights on how to stay compliant and avoid creating red flags for fraudulent billing. Also, you’ll know what phrases to look for when auditing to allow your staff to audit and train their providers in proper, compliant use of copy/cut and paste.

Learning Objectives:-

• Spot what current documentation in a patient’s record should contain;
• Identify red flags to look for concerning copied/cut and pasted or imported documentation;
• Understand coding issues (diagnoses and E/M) that arise from the documentation that’s copied/cut and pasted;
• Beware of the current CMS, HHS Office of Inspector General (OIG), and other federal agency position papers and policies on “clinical plagiarism;” and
• Locate information from your local carriers as well.

Who Should Attend:-

This program is designed for coders, billers, auditors, office managers, office administrators, Nurse Practitioners, Physician Assistants, and physicians.