Gastroenterology Coding Alert

Question: I often use previous electronic medical record (EMR) charts with the same chief complaint and then change the pertinent details. Is this OK?

Massachusetts Subscriber

Answer: Tread carefully when using templates or carrying forth medical records. The Office of Inspector General's Department of Health and Human Services and several Medicare carriers warn against using cloned documentation. Cigna Government Services states on its Web site that " 'copied and pasted' and/or cloned documentation (as available in electronic medical records) that is not medically necessary should not be counted toward the level of service billed." Doing so can constitute electronic upcoding.

To make sure your records do not appear identical, leaving you open to paybacks, follow these guidelines:

1. Show the medical necessity for the history and examination you perform.

2. Always start the history of present illness (HPI) from the ground-up. The gastroenterologist must record this new each time he performs it.

3. List associated signs and symptoms as appropriate.

If you use a typical GERD chart that includes only heartburn pain for a patient who also has weight loss and vomiting, you could overlook including the additional diagnoses, which support 99214 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision-making of moderate complexity) instead of 99213 (... an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity), which consultants associate with straightforward GERD cases.