With ICD-10 on the Horizon, Copy / Paste Functionality Must Be Examined

By Melissa Akali, MHA, CHC, CHPC, Precyse Compliance and Privacy Officer

Electronic health records (EHR) and the use of copy / paste functions are hotly debated subjects that have seen a surge in publicity recently. In fact, regulators are becoming increasingly concerned that the copy / paste function is contributing to an increase in provider fraud and abuse. Copying clinical documentation poses both clinical and compliance risk. With ICD-10 approaching and an increase in documentation complexity, organizations that allow clinicians to carry forward clinical documentation in electronic records will need to be ever more aware and increase their focus on auditing its proper use to ensure document integrity. To start, it is important that providers are educated and aware of this risk.

Inappropriate use of the copy / paste function decreases the medical record's integrity, leading to submitting false data to the insurance payer and negatively impacting patient care. Inappropriate utilization of copy / paste functions can also lead to these risks:

• Inaccurate or outdated information adversely impacting patient care;
• Redundant information, which causes the inability to determine current information;
• Inability to identify the author, intent or documentation;
• Inability to identify when the documentation was first created;
• Propagation of false information;
• Internally inconsistent or unnecessarily lengthy progress notes;
• Inability to accurately support or defend E/M codes for professional or technical billing notes;
• Upcoding;
• Documenting services not performed;
• Multiple records with duplicative information; and,
• Inappropriate billing resulting in overpayments to the facility.

Health Information Management professionals know that medical necessity is proven by diagnostic tests, services rendered, treatments provided or procedures conducted based upon the patient's illness, injury, prevention of diseases, or other patient specific needs along with documentation that meet the criterion. Based upon this knowledge, appropriate uses of copy / paste functions require specific considerations.

The first consideration is related specifically to the document. Does the document support transparency, integrity and data accuracy? A non-auditable copy / paste function that does not support transparency of authorship or origination presents risks to the document's integrity. Underlying concerns may include damage to the health record's clinical trustworthiness and integrity. Misuse of copy / paste functions can create anticipated risks; i.e., falsified patient encounters to create appearance of meeting quality of care standards.

The second consideration is related to billing the patient encounter. Is there suspected copy / paste misuse? Does the record contain an inappropriate amount of identical documentation? Does the documentation support medical necessity? The misuse of copy / paste can lead to inappropriate coding and billing contributing to fraudulent claims processing including medical conditions that were resolved in the past, physical findings, and symptoms that may be inconsistent within the health care record. If the documentation does not support medical necessity for the billed service, the claim is fraudulent.

The third consideration is auditing. Auditing allows an organization to identify gaps, create strategies, and monitor the effectiveness of its programs. When an organization identifies a copy / paste utilization gap, the organization will decide how to monitor and measure the appropriate use. Audit plan development includes determining how the copy / paste function works. To determine what can and cannot be audited, organizations will need to work with their specific vendors. Audit plan strategies should include consideration for state, federal and regulatory documentation requirements, system tracking and audit trails, organizational use observation and systems capabilities testing. Monitoring considerations include determining whether a copied event can be identified retrospectively, or whether an appropriate detailed audit log is generated when a copy occurs even in the course of documentation.

The fourth consideration is the development of organizational policies and procedures. Communication, through policies and procedures, defines the expectations on acceptable use, education, documentation guidelines, responsibility, auditing and reporting, and potential sanctions for not following the rules. If used appropriately, the copy / paste function can assist providers in working efficiently while maintaining optimal care and compliant documentation. Copy / paste functions are appropriate when:

• Information is clearly and easily distinguished from the original information;
• They cannot be mistaken from original information;
• Is auditable for identifying actual origination.

Copied information may also be appropriate when the information is based on external and independently verifiable sources, such as basic demographic information, which is stable over time. Examples of information that has been verified and has remained stable over a specific period of time include:

• Demographics
• Medications
• Allergies
• Problems
• Labs and treatment or therapies

To mitigate vulnerabilities and risk and to prepare for ICD-10 documentation complexities, analysis related to the organization's current copy and paste utilization is imperative. Understanding how clinicians are currently carrying forward clinical documentation through the copy and paste function, will contribute to the development of appropriate use policies, and the establishment of proper auditing and monitoring protocols to ensure document integrity.

American Health Information Management Association (AHIMA) (2012) Copy Functionality Toolkit – A Practical Guide: Information Management and Governance of Copy Functions in Electronic Health Record Systems.

Melissa Akali, MHA, CHC, CHPC is compliance and privacy officer for Precyse (www.precyse.com), a leader in Health Information Management (HIM) technology and services.

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