EMR Shortcuts or Pitfalls? Understanding Dot Phrases and Clinical Plagiarism

Healthcare providers face ongoing challenges in accurately documenting their services to justify the level of Evaluation and Management (E&M) services or procedure codes selected. Electronic Medical Records (EMRs) offer shortcuts like "dot phrases" and "smart phrases," which insert predetermined text into records. However, the practice of "cut and paste," where text is lifted from one record and inserted into another, raises concerns about originality, medical necessity, and clinical plagiarism.

Insurers are increasingly scrutinizing duplicative notes and the use of cut and paste, prompting a discussion on the lack of originality in progress notes. Despite significant changes to documentation rules for E&M services, note bloat persists. The CPT guidelines underwent major revisions in 2021 and 2023, emphasizing the need for concise, relevant documentation.

Analyzing your provider's documentation is crucial. How much of the note is unique to the current visit? How can you determine if there's a lack of originality in the patient's notes? Are procedure/operative reports unique to each patient?

This webinar will delve into these issues, offering insights into best practices for documentation. Understanding the nuances of EMR shortcuts, such as when to use dot phrases and when to avoid cut and paste, is vital. Participants will learn strategies for ensuring that documentation accurately reflects the unique aspects of each patient encounter, reducing the risk of audits or challenges to medical necessity. Join us to enhance your understanding of these critical documentation practices and improve the quality and compliance of your medical records.

Webinar Objectives

• Are you allowed to bring in documentation from a prior note?  Which type and how much are allowed? Is this a compliance issue?
• CPT saw changes to Evaluation and Managements coding and documentation guidelines in 2021 and 2023.  Should this and could this decrease the volume content of your provider’s notes
• Are pre-populated text entries a problem?  When are they not?
• Why does the old system of documentation put you at more risk than the new?  It’s all in the guidelines

Webinar Agenda

• When Electronic Medical Records (EMR) systems were created, one of the selling points was expediency in documentation.  I would challenge that point in talking with today’s providers.  Why?
• A progress note on a patient should have information since the last visit until today’s, what has changed?
• What is the difference between the old H&P and the new “medically appropriate history and exam”?
• What is new about medical decision making and its documentation to show support of the level of service billed for the service today. 
• What is meant by original work by the provider for this unique patient on this unique date of service.
• EMR’s have taken the often too short written note by the provider and replaced it with pages and pages of information
• How does a note meet medical necessity? or is it just yesterday’s note with a different date on it?    
  • Does it contain sections of information copied from another patient or from a consultant’s note?  Again compliance issues and potentially clinical plagiarism.  
• What does your medical record software ALLOW providers to do?  (What actions are PROVIDERS ALLOWED to take by your medical record software?)
•  Exploring and evaluating this information, along with reviewing various payers' perspectives on Cut and Paste and Clinical Plagiarism, can enhance comprehension of these issues. This session will assist attendees in developing a strategy for reviewing their records and devising an action plan to address these concerns with their providers. (A greater grasp of the problems can be attained by locating and examining this information as well as the opinions expressed by various payers on clinical plagiarism and cut-and-paste. This will assist listeners in developing a strategy for reviewing their records and developing a plan of action for collaborating with their providers.

Webinar Highlights

• Where does medical necessity fit into this puzzle?
• With the major changes in E&M service requirements what “should’ current documentation in a patient’s record contain?  Tips on how to train this information to your providers
• Do your providers know what E&M visits in 2023 should look like?
• What to look for when reviewing a record when concerned about copied, cut & pasted or imported documentation to help you spot problems
• Coding issues (diagnosis and E&M) that arise from documentation that is cut & pasted
• A quick conversation about Split Shared visits

Who Should Attend

Coders, Billers, Auditors, Office Managers, Office Administrators, Nurse Practitioners, Physician Assistant, Physician