2026 Gastroenterology Reimbursement and Coding Update (On-Demand) | November 2025-Electronic Medical Records: The Good, The Bad, and The Ugly

Video Transcription

Video Summary

The discussion focuses on the complexities and challenges of electronic medical records (EMRs), emphasizing proper documentation practices to ensure accuracy, compliance, and medical necessity. Key issues include the inappropriate use of templates and cloning—copying past notes without relevant updates—leading to redundancy and potential compliance risks, especially in hospital progress notes. Physicians are urged to create distinct, patient-specific notes with clear chief complaints, relevant history, exams, and tailored assessments and plans. Telehealth documentation requires careful template updates to reflect current standards post-pandemic. Voice recognition software demands thorough review to avoid errors, and AI-generated notes must be clearly labeled, reviewed, and finalized by providers to prevent mistakes. Security, privacy, and audit concerns are paramount, with recommendations for secure access, proper entry alterations, and author identification. CMS guidelines and OIG scrutiny stress avoiding cloning and upcoding, encouraging quality over quantity in documentation to support billing and reduce denials or recoupments.

Asset Subtitle

Kristin Vaughn, CPC, QMC, QMGC, CPMA, ICDCT-CM

Keywords

electronic medical records

documentation practices

template cloning

telehealth documentation

CMS guidelines