Wiki Copy & paste chart notes

[tnjscott]

When coding E/M is the coder ONLY responsible for the particular date of service that they are working on? I hate the feature of copy and paste! (Hypothetically) if you know that a provider has copied and pasted almost an entire chart note from a patient's prior date of service do you still use those items to determine MDM? Without those items it would simply be a minor office procedure, using this part of the note would add an additional E/M code that has already been billed for. Thank you in advance.

 

[Orthocoderpgu]

If I am reading this correctly the patient is returning for a scheduled procedure and the provider has copied and pasted the previous E/M. If that is the case, no the office visit is not billable just because it's documented. If the decision to perform the procedure was made at the previous visit, no E/M would be billed. I'm old school, in my world the copy and past function should NEVER be used. Each document should stand on its own and each document should reflect what happened specifically on that date of treatment. As the physician is treating a medical condition that condition should improve with treatment. The documentation should reflect that. If you have a compliance compartment bring this up. Copy and pasting creates a multitude of problems with documentation. Get it turned off.