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EMR documentation

Glenda Posted Tue 09th of October, 2018 15:09:46 PM
The physicians are using an electronic medical record, and it appears that they are repeating the same note. A class I attended stated that in the CMS guidelines this is wrong, and has been recently reported in the Medicare guidelines as wrong and incorrect. I can not find the site for this on line at their web site. I am not sure if this is transmittal or general medicine documentation. Thank You. Glenda E Flemister MD, FACP, FCCP
SuperCoder Answered Wed 10th of October, 2018 07:36:39 AM

Hi Glenda,

Kindly provide us with some more documentation and details to know, what is exactly been repeated; and guidelines regarding what needs to be provided, so that we confirm it to be right or wrong. Thank you.

Glenda Posted Wed 17th of October, 2018 13:31:22 PM
In the documentation it appears that multiple physicians are using the EMR in the examination with the same phrase, “skin- warm and dry” appears to be a copy & paste. I understand that CMS does not permit this, and this does not meet coding criteria. I need to know where I can locate this on the Medicare/CMS web site. Thank you. G Flemister MD, FCCP, FACP,
SuperCoder Answered Thu 18th of October, 2018 14:01:44 PM

Thanks for the additional information. The examination is meant to paint a clear picture of the physical examination findings for each encounter.  It is not appropriate to clone an examination from visit to visit.  There are cases where a template will be used within the EHR and that could be what you are seeing in the providers' documentation. Be sure double check to see if templates are being used.  If a template is being used, this is not against CMS guidelines if you can determine that they are not over documenting, their examination pertains to the reason for the visit, and that they are indicating abnormal findings.


There are also certain areas where it is appropriate for a provider to bring forward or copy and paste documentation from one visit to the next if they have indicated in the documentation that they have reviewed the information and documented the encounter date that was copied.  Please find below the CMS E/M documentation guidelines which indicates the portions of the note that may be copied and pasted.  Also, I have included an OIG document outlining their findings regarding cloning and a CMS whitepaper discussing the problem with cloning.  Hopefully these documents will help you.

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