Mike Enos, CPC, CPMA, CEMC and Nancy Enos FACMPE CPMA, CEMC, CPC-I, CPC have authored a series of articles published in MGMA's Connexion Magazine.  The September issue featured the first part in the Code of Conduct Section, and Part 2 has now been published in the October edition.

In the September article EMR Risk- If it wasn't done, don't document it: Tackling E&M coding errors in the age of EHR's  we explored the growing trend of overdocumentation made easier by EMR's.  We discussed the causes and risks associated with overdocumentation, as well as proper ways of documenting lengthy visits to make sure you are reimbursed appropriately.  In this article, we investigate the pitfalls and risks related to overdocumentation and cloned notes specifically.

Cloned notes (using the exact same verbage from patient to patient), copied notes, and automatically generated notes should be examined closely, and physicians should be trained on how to delete, correct, and authenticate the contents of their notes to ensure that the notes actually reflect the services provided, and nothing more.  Often times in copy-and-paste notes, or other EMR notes where information from previous services are "pulled forward" into the note, we find information that is erroneous, superfluous, and sometimes directly contradictory with what is described in the history of present illness or the examination.

EHR's that have a "coding tool" can be especially risky, when the level is calculated based on data elements, and not medical necessity.