Breaking free of copy/paste: OIG work plan cracks down on risky documentation habit.

摘要

ACCORDING TO THE Centers for Medicare and Medicaid Services, evaluation and management (E/M) services accounted for $28 billion in Medicare Part B payments during a one-year period.1 And of these, 8.4 percent were billed at the wrong level—either too high or too low. Chasing these potentially inappropriate payments is now part of the OIG's new work plan and, consequently, a new focus area for HIM professionals. A common documentation vice may be fostering the 2013 OIG work plan's focus on potentially inappropriate E/M service payments—cutting and pasting patient encounter notes within EHRs. But HIM professionals can team up with physicians, other clinicians, and IT departments to improve documentation and mitigate their audit risk.