Open Access Research article

Following the money: copy-paste of lifestyle counseling documentation and provider billing

Mary Zhang1, Maria Shubina1, Fritha Morrison1 and Alexander Turchin123*

Author Affiliations

1 Division of Endocrinology, Brigham and Women’s Hospital, 221 Longwood Avenue, Boston, MA 02115, USA

2 Harvard Medical School, Boston, MA, USA

3 Quality Performance Management, Partners HealthCare System, Boston, MA, USA

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BMC Health Services Research 2013, 13:377  doi:10.1186/1472-6963-13-377

Published: 2 October 2013



Evidence suggests that copy-pasted components of electronic notes may not reliably reflect the care delivered. Federal agencies have raised concerns that such components may be used to justify inappropriately inflated claims for reimbursement. It is not known whether copied information is used to justify higher evaluation and management (E&M) charges.


This retrospective cohort study aimed to assess the relationship between the level of evaluation and management (E&M) charges and the method of documentation (none, distinct or copied) of lifestyle counseling (diet, exercise and weight loss) for patients with diabetes mellitus. To determine the association, an ordered multinomial logistic regression model that corrected for clustering within individual providers and patients and adjusted for patient and encounter characteristics was utilized. E&M charge level served as the primary outcome variable. Patients were included if they were followed by primary care physicians affiliated with two academic hospitals for a minimum of two years between 01/01/2000 and 12/13/2009.


Lifestyle counseling was documented in 65.4% of 155,168 primary care encounters of 16,164 patients. Copied counseling was identified in 12,527 encounters. In multivariable analysis higher E&M charges were associated with older patient age, longer notes, treatment with insulin, medication changes and acute complaints. However, copied lifestyle counseling was associated with a decrease of 70.5% in the odds of higher E&M charge levels when time spent on counseling (required to justify higher charges based on counseling) was recorded (p<0.0001). This finding is opposite to what would have been expected if the impetus for copied documentation of lifestyle counseling was an increase in submitted E&M charges.


There is no evidence that copied documentation of lifestyle counseling is used to justify higher evaluation and management charges. Higher charges were generally associated with indicators of complexity of care.

Electronic medical records; Copy-paste; Cloned documentation; Healthcare costs; Physician billing; Lifestyle counseling