Copying and pasting documentation within the electronic health record is a practice whose time to stop has come as industry forces demand better documentation. “I think everyone in the industry recognizes it is an issue,” says Michelle Mitcheff, physician services auditor at Indiana University Health’s Southern Indiana Physicians practice in Bloomington, IN.
But awareness isn’t yet significantly translating into action and that action soon may be forced. While putting together its 2013 work plan, the HHS Office of Inspector General took the stand that EHRs being used to copy and paste are making fraudulent activity easier, although it is yet unknown what action the office will take.
During a session at the AHIMA Conference in Atlanta, Mitcheff will walk through why copy and paste has to become history. “I recently sat in on training by a big-name vendor teaching providers how to copy and paste,” Mitcheff says. “But they weren’t telling providers they can be penalized for that.”
For instance, if an insurer is conducting a complex review not just of billings but the entire medical record and finds notations copied and pasted, a provider cannot prove good faith in documentation of services provided, she notes. And the practice also makes it more difficult to win appeals for a range of other audit programs including Medicare RACs.
Everyone’s talking about copy and paste, “but you need to know within your organization the breadth of the problem or if there is a problem,” Mitcheff advises. And then, you need to press your vendors to come up with solutions that make documentation easier without copy and paste.
Today, third party tools are available to highlight copied and pasted documentation, and they can help an organization understand the prevalence of the practice. There also are safety issues with copy and paste. For instance, erroneous information put in the EHR that continues to get re-used in further documentation means that the error won’t be found and the ramifications can be terrible. Mitcheff recalls an incident where a tumor on the right kidney was noted as being on the left, which was removed--and the diseased right kidney then also had to be removed.
During her session, Mitcheff will issue a call to action with HIM professionals among the leaders coming to the table with vendors to find a solution. “Internally, you need to be in the know about what is happening and we need to be a catalyst of change.”
Education session 10141, “Chief Complaint: Copy and Paste,” is scheduled at 1:00 on October 28.
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