Thank you, Tammy, for sharing the update from your copy-paste policy. Could you please confirm whether updates to the patient's assessment and plan are required if Medical Decision Making (MDM) is used for billing, even when the assessment and plan remain unchanged from the clinician's previous visit with the patient?
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noel wagner
Associate Director Physician Compliance
University of North Carolina Hospitals
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Original Message:
Sent: 05-13-2025 09:48:25 AM
From: Tammy Morris
Subject: Copy Paste Policy
Hi Noel,
We have recently updated our copy and paste policy to state that any text carried forward from a previous visit, the time must be reentered (even if the amount of time is the same). The auditor verifies in Epic that the time has been updated in these instances. I provided the verbiage below for you.
Thanks,
Tammy
Original Message:
Sent: 5/13/2025 7:26:00 AM
From: noel wagner
Subject: Copy Paste Policy
Hello,
We are in the process of updating our copy-paste policy and would appreciate it if anyone could share their current policy with us. Specifically, we are interested in understanding the use of disclaimers when there are no updates to the note. Additionally, we seek to determine the minimum expectations for accepting a note where the majority of the text has been carried forward from a previous visit. Thank you for your assistance.
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noel wagner
Associate Director Physician Compliance
University of North Carolina Hospitals
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