The purpose of the medical record is to help the doctor and other doctors and healthcare professionals treat a patient. Medicare and other third party payers can only be expected to pay for work performed at an E/M service on that date of service. A payer doesn’t pay for work done at a previous visit, and copied into today’s note. With copying and pasting notes in EHRs, the rule is that you should not document it if you did not ask it, review it, examine it or consider it. If you copied from a previous note, read your new note and see if it contains any details that do not meet one of those criteria. If so, delete that element.
Let’s divide the History of the Present Illness (HPI) into two sections: a clinical summary and a section called, “since last seen.”
Clinical summary within the HPI: At times, it is useful for a physician/NPP to copy a clinical summary of the patient’s condition from a previous note. When doing this, label it as copied and date the note from which it was copied.
Clinical summary from 1-4-14 “XXXXX”
Since last seen: In this section, add the HPI elements or status of the patient’s condition since the last visit.
ROS: Document the ROS as asked and reported by the patient today. I don’t recommend copying from a previous note, even though the Documentation Guidelines allow it. It doesn’t make sense to me and leads to inaccuracies. If the patient fills out a paper or electronic questionnaire, be sure to initial and date it.
Past medical, family and social history: This can be imported from a previous note as long as it is reviewed with the patient. Either update the history or note that no changes were required. Only import the sections of the note that are needed for today’s visit. I suggest refraining from importing family history routinely. For 99214 only one of past medical, family, or social history is needed. For 99215, two of past medical, family and social history are needed. If family history isn’t relevant to the visit, don’t add it to the record. It contributes to the appearance of an overly cloned note.
Exam: Exam is always new and should describe only exam elements documented at this visit. Some clinicians find it useful to import a previous exam as a reminder of abnormal elements for this patient and state it is more accurate than “normal exam” because it relates to the patient being seen. I personally do not recommend copying the exam from a previous note. But if it is copied, it must be edited and reflect only exam elements performed at this date.
Data: Many clinicians find it useful to carry forward in a progress note results of diagnostic tests. It is easier than looking through the computer for tests results that may require multiple clicks and many minutes to find. This is useful, clinically. Only new data either ordered or reviewed during the visit would be credited to determine the level of service. Historical data re-reviewed could be credited, such as, “Comparing the EKG today with the EKG from 2012…”
Assessment and plan: A physician is paid for the conditions being managed at this visit, not for conditions managed by another physician or for conditions not addressed or reviewed at this visit. The assessment should clearly note which problems were addressed today.
If the patient has problems not addressed at this visit, but listed in the A/P, label these as such. Insert a statement before the list, “other medical problems not addressed at this visit.” Clinicians find it helpful to import this data into the note. But, then, don’t use it to select a level of E/M service if the conditions were not addressed at this visit.
I suppose in a blog it is redundant to say this is my opinion? This is my opinion, supported by reviewing OIG reports, the Documentation Guidelines, discussions with physicians, lawyers, coders and experience reading thousands of notes a year. Obviously, obtain professional advice before adopting any policy. CMS has not released a policy about this topic as of this date.