I have a Hospitalists that clones (copies and pastes) all his notes despite being told about this. I’m having a battle with myself on how to codes his follow ups. My Managers says to code per documentation which I do. Since his notes are cloned and his template is set for a COMPREHENSIVE exam each time (whether medically necessary or not), his follow ups are scored as level 3’s. But what happens when he adds a paragraph to the top of the cloned note stating patient is improved and goes into detail about that? He then adjusts time spent from 35 or 40 minutes down to 25 or 30 minutes. All of this indicates to me a reduced level. I really struggle as these should be coded as level 2’s even though the rest of the note scores a level 3!

I’m trying to justify scoring these as level 2’s because the E/M guidelines are just that…guidelines. The Medical Necessity just isn’t there to ethically score any higher. But yet………when you have 20 pages cloned from when the patient was in ICU……….what does one do?

I’d surely appreciate any guidance in this.
Thank you.