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

Why This Topic Matters

Accurate documentation is central to E/M level selection, audit defensibility, and record integrity. This article helps readers understand why generic or duplicated note content can create compliance risk and why visit-specific documentation remains important.

Article Sections

1. Courtesy updates aren’t MDM

   Discusses general documentation about communication with other providers and how such statements are treated in relation to office E/M medical decision-making. It also summarizes the broader concern about routine boilerplate language in notes.

2. Exact copies aren’t MDM

   Covers copy-and-paste documentation practices, the need to reflect what changed from one encounter to the next, and the importance of visit-specific charting. It also references guidance from CMS and a Medicare administrative contractor.

3. Resources

   Lists the source materials referenced in the article, including CPT Assistant, a CMS fact sheet, and contractor guidance.