For patient notes, copy and paste with care to keep MDM on the level

Why This Topic Matters

Accurate documentation is central to selecting office E/M levels and supporting the medical record. The article highlights why routine or cloned note content can create compliance and audit risk, making it relevant for practices that rely on E/M documentation and MDM-based coding.

Article Sections

1. Courtesy updates aren’t MDM

   This section discusses communication with other providers and the general documentation issues raised when routine note language is used to support office E/M coding. It summarizes guidance from CPT Assistant and related sources on what kinds of note content are relevant to the visit record.

2. Exact copies aren’t MDM

   This section focuses on copied or repeated documentation across encounters and the need for visit-specific charting. It also references broader documentation guidance from CMS and a Medicare administrative contractor.