Let’s revisit documentation cloning

Q: Our physician group is part of a large healthcare network, and we seem to be getting more and more pushback from our physicians regarding cloning. Can you help us explain the seriousness of cloning to our physicians?

A: While we have addressed cloning in previous articles, it’s a topic that deserves revisiting. As you point out, many providers feel that the shortcuts that the electronic health record (EHR) trainers “sell” are the way that they should use the EHR, especially since the trainers don’t always focus as much attention on good documentation habits.

Shortcut usage is only enhanced when providers see other provider notes that seem to utilize cloning techniques. Regardless of how you want to say it- cloning, copy/paste, or templates-the bottom line is that medical record documentation that is exact or very similar could be a basis for payer recoupment.

When cloning was addressed in a recent government fraud prevention provider fact sheet (found at bit.ly/EHRfact-sheet), it detailed that, “The medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter. Simply changing the date on the EHR without refl ecting what occurred during the actual visit is not acceptable.”

I am increasingly hearing from providers that, when reading other providers’ notes, they cannot tell what is going on with a patient because the documentation doesn’t refl ect changes in problem(s), symptom(s) or treatment(s). An EHR should not be used to create “cookie-cutter” documentation.

Over-documentation

An issue that goes hand-in-hand with cloning is over-documenting. // ABOUT This is the practice of inserting false or irrelevant documentation to create the appearance of supporting a higher level of service. Some EHRs auto-populate fi elds and/or generate extensive documentation with the single click of a checkbox. If this information isn’t appropriately edited by the provider, it could be inaccurate or cause discrepancies.

For example, documentation that showed a male patient had received a pelvic exam would certainly be a cause for payer concern, and probable recoupment for the service.

// PITFALLS These types of features can produce information suggesting that the practitioner performed more comprehensive services than were actually rendered, which would result in an improper payment. When a claim is paid without the appropriate supporting documentation, payment must be returned to the payer.

// PAYER’S VIEW If today’s progress note for a patient visit looks identical or nearly identical to a previous DOS, a payer will question the medical necessity for today’s visit and recoup the payment for the service. In a payer’s view, the provider has already been paid for the services performed, and the patient’s condition(s), symptom(s) or treatment(s) haven’t changed to support medical necessary for the visit. 

Renee Dowling is a coding and billing consultant with VEI Consulting in Indianapolis, Indiana. Send your coding questions to: medec@ubm.com.