Medicare backdating documentation

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Copying information can go farther, as noted in a paper in the April 2008 issue of the New England Journal of Medicine.Authors Pamela Hartzband, MD, and Jerome Groopman, MD, who practice at Beth Israel Deaconess Medical Center in Boston and teach at Harvard Medical School, write, “Many times, physicians have clearly cut and pasted large blocks of text, or even complete notes, from other physicians; we have seen portions of our own notes inserted verbatim into another doctor’s note.This “copy and paste,” or pulling forward of information from past visits, was meant to save time on the busy hospital floor.It resulted in a misrepresentation of the patient’s stay and a fraudulent submission for reimbursement.As the patient’s health worsened, a hospital stay of days turned to weeks.But through the various tests and physician visits, the progress notes generated in the hospital’s electronic record system looked similar.The commonwealth-trained (and more prudent) approach would be to insert the date only when the last party has signed and to use a date no earler than the date of that last signature.This should cover the majority of cases that come across corporate counsel’s desk.

But the practice can lead to serious consequences for both patient care and reimbursement, some auditors say. A lot more than you would expect,” says Patricia Trites, MPA, CPC, CHP, HCC, CHCO, cofounder of the Advocates for Documentation Integrity and Compliance and CEO of Healthcare Compliance Resources, based in Augusta, MI.Such documentation may also show physicians performing services they only performed once in the past, leading to over reimbursement.Documentation should be recorded for each specific encounter, Trites says. That’s because providers are paid for the work they perform in each encounter, and that includes part of the documentation, she says.In the US, however, there seems to be have been much more consideration of the issue (at least according to my Google search results).Despite recent controversies surrounding the backdating of executive stock options, the general attitude in the US is that backdating is not wrong (or right), per se.

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