Speaker: Betsy Nicoletti
Copy and paste: what’s your policy? The OIG has issued stern warnings in recent reports to physicians and CMS about the dangers of copy/paste and over-documentation in EMRs. It would be ironic if it were not so frustrating: CMS provided economic incentives to adopt EMRs but then cautions about using them in a way that might be convenient or take advantage of its features. What policy should a group adopt about copying, carrying forward, and assuming authorship of previously recorded data? And, what constitutes over-documentation? CMS agreed with the OIG recommendation to develop XXX Until they do, medical practices must define their own policies related to use of the EMR that help clinicians get through the day, preserves the integrity of the medical record and protects the medical practice.
This webinar will:
- Review the recent OIG reports.
- Review the Documentation Guidelines regarding carrying forward parts of E/M notes.
- Describe current functions in some EHRs that allows for carrying forward entire notes.
- Suggest what parts of a note should be copied and how to label them
- Describe how an auditor assesses “over-documentation”.
- Suggest components of a policy for a medical practice.
After listening participants will be able to:
- Describe over-documentation.
- Develop a list of audit functions that should be in the EHR and query their vendor.
- Assess notes for over-documentation and copy/paste.
Meet Our Expert Speaker:
Betsy Nicoletti, is the co-founder of Codapedia.com, a wiki devoted to physician reimbursement. She is also the author of The Field Guide to Physician Coding 2nd and the Auditing Physician Services. She developed The Accurate Coding System™ to help doctors get paid for the work they do. As a certified coder, Betsy simplifies complex coding rules for practitioners and engages physicians in a positive and respectful way, which encourages attention and accuracy in their coding. Besides doing auditing and compliance work, she is a speaker, writer and consultant in coding education, billing and accounts receivable management.
She holds a Masters of Science in Organization and Management from Antioch, New England, and has worked in and around physician offices for over 25 years. She became a certified coder in 1999. Betsy is a member of the National Speakers Association, the Medical Group Management Association and the Healthcare Financial Management Edition.
You may have heard her speak at conferences sponsored by MGMA, DecisionHealth, ACHE, HFMA, AMBA, The Coding Institute, The Journal of Medical Practice Management and the World Research Group.
Betsy was awarded the 2010 QuantiaMD Community Choice Award for Excellence in Knowledge and Sharing Information. She was the only person to win the award who was not an MD, showing the tremendous value the physician community places on her!