May 2013

Read Between the Lines
By Lisa A. Eramo
For The Record
Vol. 25 No. 8 P. 18

Identifying harmful copy-and-paste documentation can help curb serious coding errors.

Like any good story, a medical record should be consistent and relatively easy for the reader to follow, presenting events in a logical sequence. However, as physicians begin to document in the EHR, the patient’s story—the crucial element necessary for coding—can become jumbled and sometimes even unreadable. Coders may begin to see nonsequential dates on progress notes, repetitive documentation that includes no new information, diagnoses that don’t correspond with treatments, or even inconsistent demographic information such as the patient’s name.

The culprit? Experts say EHR functionality that allows clinicians to copy and paste documentation within a record or from one record to another likely is to blame. This practice, sometimes referred to as cloned documentation, creates a host of problems for coders trying to ensure coding accuracy and data integrity.

“You lose the patient’s story in these notes that replicate what has been previously documented,” says Cassi Birnbaum, MS, RHIA, FAHIMA, CPHQ, vice president of HIM at Peak Health Solutions. “It’s hard to tell the old from the new and the relevant from the irrelevant. It becomes completely unreadable.”

Experts say the problem is growing, and it may spiral out of control if hospitals don’t develop policies to address it and/or work with their EHR vendor on potential solutions.

The Office of Inspector General (OIG) is aware of how an EHR may contribute to fraud and abuse, including inaccurate coding. In its work plan for fiscal year 2013, the OIG stated it will look at fraud vulnerability presented by EHRs “as articulated in literature and by experts to determine how certified EHR systems address these vulnerabilities.” Experts say copy-and-paste documentation likely is on its list of targets.

Coding Dilemmas Abound
When clinicians copy and paste information, it potentially can wreak havoc on coding compliance. “If coders are reading information that’s copied and pasted, they may be looking at incorrect or inappropriate documentation that they’re then using to assign codes,” says Ann Barta, MSA, RHIA, director of HIM solutions at AHIMA.

For example, a physician may copy and paste a condition from a previous encounter that a patient no longer has or that isn’t even relevant to the current hospital stay. In the inpatient setting, this frequently occurs with patients who have longer lengths of stay or those who are admitted frequently because of chronic illnesses, Barta says.

Copy-and-paste documentation doesn’t affect only coding compliance; it also can negatively impact productivity—no coder wants to contend with that, particularly as the industry moves toward ICD-10. “It affects coders because they need to read through a lot of extraneous information,” Birnbaum says. “They might miss [diagnoses] that are really pertinent to the stay and that support treatment or make a difference from a CC [complication/comorbidity] and MCC [major CC] standpoint.”

The surge in EHR implementations has exacerbated problems with copy and paste, according to Birnbaum, who says the situation is primarily a “by-product of a poorly designed EHR” that encourages clinicians to take shortcuts that ultimately could put the facility and themselves at risk.

For example, Birnbaum recently consulted at a provider site where the EHR automatically created a progress note based on the previous date and autopopulated it with previous information. It’s far too easy for clinicians to save the note and move on rather than take the time to validate the information’s accuracy, she says.

Ironically, many clinicians are equally as frustrated by copy-and-paste documentation, says Jon Elion, MD, founder and CEO of ChartWise Medical Systems, who says he experienced that frustration firsthand when a coder recently queried him regarding the location of a patient’s heart attack. He had clearly documented an anterolateral myocardial infarction (MI), but when browsing through the chart, he realized that a physician assistant had indicated a posterior MI.

“Every other progress note in the chart propagated the fact that it was a posterior MI,” Elion says. “My note was correct, but everyone else had copied and pasted this erroneous note.”

Physicians themselves should be concerned with copy-and-paste documentation not only because it affects clinical care but also because it can affect proper evaluation/management (E/M) code assignment, says Jacqueline Thelian, CPC, CPC-I, CEO of Medco Consultants, who notes that physicians frequently copy and paste the review of systems and exam portions of a visit without thinking about whether it might raise a red flag for an auditor. “When we code it out, usually the history and physical meet higher criteria but the medical decision making doesn’t,” she says. “Clients will ask us to downcode based on the medical decision making, which is the right thing to do.”

In its work plan, the OIG said it will monitor potentially inappropriate E/M payments because “Medicare contractors have noted an increased frequency of medical records with identical documentation across services.” This identical documentation doesn’t meet medical necessity criteria, Thelian says.

First Coast Service Options, the current Medicare administrative contractor for Puerto Rico, the US Virgin Islands, and Florida, published information about cloned documentation and medical necessity in 2006, and many other contractors have followed suit since. In its Medicare A Bulletin for the third quarter of 2006, First Coast noted the following:

Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to lack of specific, individual information … Providers frequently ‘over document’ and consistently select and bill for higher-level E/M codes than medically reasonable and necessary. Word processing software, the electronic medical record, and formatted note systems facilitate the ‘carry over’ and repetitive ‘fill in’ of stored information. Even if a ‘complete’ note is generated, only the medically reasonable and necessary services for the condition of the particular patient at the time of the encounter as documented can be considered when selecting the appropriate level of an E/M service. Information that has no pertinence to the patient’s situation at that specific time cannot be counted.

When providing physician education, Thelian focuses on medical necessity and accuracy. “I tell them, ‘Write your note the way you would have to defend it at an ALJ [administrative law judge] hearing,’” she says.

Thelian recalls attending an ALJ hearing that featured a patient record with 10 pages of current medications. Two of the medications listed had a deadly interaction, suggesting that the provider had simply copied and pasted information without taking the time to verify or update it.

Accuracy is essential, Elion says. “I want physicians to verify information themselves,” he says. “I want the patient to be asked questions two or three times even though they may find it annoying. I don’t want errors to get propagated and promulgated through the chart.”

Attacking the Problem
Documentation and coding always should reflect a patient’s current circumstances, says Claudia Tessier, RHIA, MEd, a Boston-based HIM/HIT consultant. “If data being copied and pasted appear to be current, then it’s misleading to the next physician, and it’s misleading to the coder,” she says. “It creates a medical record that’s, in a sense, fabricated.”

Perhaps the most egregious example of inappropriate copying and pasting is when a clinician mistakenly copies information from one patient chart into another. “It’s really about patient care and the accuracy of the data on which you base patient care,” Tessier says. “It’s a clinical issue that impacts coders.”

Experts agree that errors involving information from another patient’s chart are difficult to spot because coders may not even be aware that the information is inaccurate. It’s also extremely difficult to monitor and control copy-and-paste documentation simply because of the sheer number of clinicians who may document in the EHR, Tessier says. However, she suggests coders ask the following questions when reviewing documentation for coding:

• Is it current?

• Is it relevant to the encounter?

• Does it relate to the current admission?

As for indications that information has been copied and pasted, coders should be alert to the following clues:

• incorrect patient name and/or sex (eg, the physician documents that the patient is female, but the review of systems repeatedly uses the pronoun “he”);

• incorrect or nonsequential dates, particularly when those dates fall outside the parameters of the particular hospital stay or encounter;

• a comprehensive history for a patient who presents regularly or was seen recently; and

• the review of systems doesn’t match the presenting problem. For example, a patient presents because of joint pain and swelling, but the musculoskeletal review of systems is negative, and the patient denies joint pain and swelling. “It’s cut and pasted,” Thelian says. “You get conflicting information within the note itself.”

She notes that coders in a physician practice setting may want to consider accessing the audit trail when coding. “We’ve always been detectives, and we question the integrity of the data,” she says. “We do this because we want to make sure that our providers are compliant and that they’ll be able to keep the money that they’re paid.”

However, reviewing the audit trail may not always be practical or even possible in the facility setting. “If you think about a typical inpatient chart where five or six providers are documenting and the stay is three or four days, it would probably more than double the amount of time it would take the [inpatient] coder to code,” Barta says.

As with any inconsistent documentation, coders must query for clarification. However, in a suspected copy-and-paste situation, it’s best to step gingerly. “You wouldn’t want to come out and accuse a provider of copying and pasting,” Barta says. “You’d have to word it clinically and ask the question for clarification.”

Finding a Fix
Many hospitals are starting to draft policies on proper use of copy-and-paste documentation, Barta says. “Copy and paste is getting a lot of publicity, and most of the time it’s not positive,” she says. “I think it’s more on the radar screen now than it has ever been.”

Such a policy should include input from HIM, HIT, the C-suite, medical staff, quality assurance, risk management, and coders, Tessier says. Essential policy elements include the following:

• a definition of what constitutes copy-and-paste documentation (eg, a reproduction of a substantial portion of text from somewhere else in the chart).

• an explanation of how copy-and-paste documentation will be identified. Will the EHR automatically identify it or must clinicians use a citation or preface documentation, such as “As stated in Dr Smith’s note on March 30”?

• a list of what information can be copied and pasted. Physicians should be able to copy and paste abnormal lab values into a progress note or another document, Birnbaum says. Also consider X-ray and pathology reports, Elion says. If physicians can copy and paste an X-ray report into their progress notes and then comment on that report, coders can immediately code from that information. Otherwise, they can’t code directly from the report, he notes. The same is true for a pathology report after a biopsy. Instead of documenting “The pathology report confirms cancer,” the physician can copy and paste the specific findings and details—all of which are relevant for coding.

• a list of what information cannot be copied and pasted (eg, substantial portions of a physical exam).

• protocol for how coders, clinicians, and others should address potential copy-and-paste documentation. Tessier says coders may need to notify a supervisor or clinical documentation improvement specialist. “Coders should be part of the solution and team to deal with and diminish copy-and-paste documentation,” she says. “Their role beyond that will need to be determined by the institution.”

Peer (ie, physician-to-physician) pressure may be one way to address the problem. As with coders, physicians must search among pages of irrelevant information to find pertinent details for clinical care. Birnbaum says it may be effective for physicians themselves to raise awareness and provide feedback to one another about how copy-and-paste documentation can affect—and potentially delay—important clinical decisions.

EHR vendors also need to play a larger role in compliance, according to Birnbaum. For example, when documenting progress notes, clinicians should be able to hyperlink back to original information in the EHR rather than copy and paste that information into a new document. EHRs also should be able to automatically populate the discharge summary with pertinent diagnoses, treatments, and procedures but require physicians to summarize the postdischarge plan and any medications. “It really obviates the need for copy and paste,” Birnbaum says. “It also provides a carrot to the physician because he or she only needs to focus on the new documentation.”

Elion agrees, stating that EHRs should be able to clearly identify information that has been copied as well as the source (attribution) of that information. If EHRs had this functionality, clinicians would be more accountable because others would be able to easily detect any shortcuts they take, he notes.

According to Tessier, some organizations are incorporating plagiarism software into their HIT systems to identify documentation that has been copied and pasted. However, Elion says this approach is backward thinking. “Computer systems should always assist you in doing the right thing up front and not catch you doing the wrong thing,” he says. “Guide me how to correctly write a progress note using copy and paste. Don’t go back afterward and try to detect my use of it.”

Tessier recommends asking an EHR vendor the following questions:

• Does the system allow physicians to copy and paste? If so, how does the system identify that information? For example, is the text highlighted?

• Can physicians attribute copied information to the original author? If so, how?

• Is there an option to completely disable the copy-and-paste function? If not, how does the system facilitate audits? Is there an audit trail that can be monitored regularly?

Looking Ahead
Once ICD-10 goes live, hospitals must pay even closer attention to the perils of copy-and-paste documentation. Tessier says coders will be more dependent on procedure-specific details, increasing the possibility of significant errors and closer scrutiny. “With ICD-10, documentation will be increasingly important and increasingly referred to,” she says. “It’s going to be looked at more and more by payers and auditors.”

— Lisa A. Eramo is a freelance writer and editor in Cranston, Rhode Island, who specializes in HIM, medical coding, and health care regulatory topics.