Documentation: Carrying Forward or Ineffective Use of Templates

June 30th, 2017 - Shannon DeConda

I often receive questions such as the below from our members regarding E&M scoring:

"I have heard that if information is 'cloned' or 'moved forward' from a previous visit, we should not count that info in scoring. However, I have also read that if a provider moves the info forward and also documents that it is the same or unchanged, then we are able to use that information. Can you clarify?"

The problem is that everyone says that CMS says you cannot copy/paste and/or clone documentation, but try to find that in black and white. CMS now has a clarification posted in the Program Integrity Issues in Electronic Health Records: An Overview that defines copy/paste. It does not say it cannot count, but actually gives us a definition of copy/paste. Even this document gives some definition, but unfortunately it does not provide you with concrete guidance on the matter.

What I can say is that I believe documentation is now superseding the actual care of the patient in healthcare, and given that, I think we must use our knowledge and place true relevancy as to what was carried forward. If the PFSH is carried forward- is that truly wrong? Well, considering that Documentation Guidelines (DG) allows a patient themselves to document their own PFSH or ancillary staff to perform the work- as long as the provider has reviewed it- it counts. How can you argue that carrying forward the sit me information, provided it was reviewed by the provider, is any less traumatic?

We know that HPI, Exam, and Medical Decision Making (MDM) must all be specific to the patient encounter and relevant to the patient's presenting problem. Information carried forward may be found in HPI typically occurs when the provider pulls the old HPI from a previous encounter. Provided they then label it as previous HPI and today's HPI for the purposes of good patient care- then it's completely acceptable. Exams are typically not brought forward, but rather a product of "push button finger" within the EMR- so before you consider these as carry forward; consider that the provider may just not be effectively using their templates.

Diagnoses will sometimes carry forward as a problem list for the patient, but again that would not be a problem, because we are only going to count what was relevant to today's encounter. Regarding the data and complexity of what was reviewed, I have seen MANY inpatient EMRs such a Cerner that hold ALL inpatient testing in every note. Again, I'm not going to ping the provider for carrying forward, but rather not count it if he/she doesn't create the relevancy. For example- Patient is IP for 10 days and the chest x-ray from admit day 1 is on my 99231 encounter for day 9 (as well as every day), we must be sensible and understand that unless there is a reasonable cause within the documentation that the provider has needed to re-evaluate that x-ray for 10 days- then we just don't count it.

The plan of care should ALWAYS be patient and encounter specific. I do see more and more that encounters are looking macro populated, but think about what many of these are. For example, Provider told the patient to take vitamins and wash eye lids effectively everyday.... Will that really affect your encounter to a higher level of service? Then let it go!

So, my answer is this: evaluate if the documentation is REALLY carry forward or just an instance of poor template usage. If it is carry forward, is the information carried forward really impacting the care of the patient and pertinent to today's visit?

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