Tips to understand EHR note cloning

Q: Where can I find specific guidance on cloning and electronic health record (EHR) issues?

A: Regardless of the capabilities of their EHR, it is imperative that physicians understand the coding process, and only assign codes that reflect the actual level of medical decision-making and hence medical necessity.

The Centers for Medicare & Medicaid Services website has an “Electronic Records Toolkit” that addresses specific concerns and violations regarding note cloning, as well as the federal definitions of these. Some of the more relevant portions are described below.

Copy and paste: Selecting data from one location and reproducing it in another; also called “cloning,” “cookie cutter,” “copy forward” and “cut and paste.” Clinical plagiarism occurs when a physician copies and pastes information from another provider and calls it his or her own.

Healthcare professionals have stated that copying and pasting notes can be appropriate and eliminate the need to recreate every part of a note and re-interview patients about their medical histories. However, defaulting or copying and pasting clinical information using existing documentation from other patient encounters in a different health record facilitates billing at a higher level of service than was actually provided.

Templates: Using predefined text and text options to document the patient visit within a note. 

Macros: Expanding text associated  with abbreviations or specific keystrokes.

Some EHR systems use templates that complete forms by checking a box, macros that fill in information by typing a key word, or auto-population of text when it is not entered.

Problems can occur if the structure of the note is not a good clinical fit and does not accurately reflect the patient’s condition and the services to him or her. These features may encourage overdocumentation to meet reimbursement requirements even when services are not medically necessary or are never delivered.

Upcoding: Using documentation to upgrade the level of care provided.

Some  EHR systems prompt physicians on what additional documentation is necessary to justify using a higher billing code, even when existing documentation is sufficient to justify the code that has been entered. In 2012, a joint letter from the Departments of Justice and Health and Human Services to several national hospital associations expressed concern that some providers might be using their EHR systems to upcode the documented intensity of care provided as a method of improperly increasing reimbursements. Both departments indicated their willingness to use the tools available to them to detect upcoding and prosecute offenders.

Fabrication: Copying information or creating text to show that treatment was delivered or occurred at a  level higher than what was actually provided. 

Notice that the theme of many of these is the intent to upcode or increase reimbursement. Many providers simply use the tool that is at their disposal, or that they are given. 

Q: The majority of my primary care practice are middle-aged to older patient following up on chronic problems, health maintenance or both. Our internal auditor keeps telling me that I need an history of present illness (HPI) on these when I have a complete exam and I typically list three or more problems in the assessment and plan. Since these follow up visits are a “2 of 3” code category, per Current Procedural Technology (CPT). Why do I need an HPI? This seems like just extra typing.

A: You are correct that the established patient code subcategory does not require an HPI, or even a history section. Be careful though: What the CPT says, and what a payer may look for in terms of either quality or completeness, may be quite different.

Not being familiar with the auditor’s specific concern I can’t say exactly why they want this-but I do have some thoughts on the subject. Some words you used in your question point this way.

Even if your Assessment and Plan (A/P) lists several diagnoses, are the status of each problem (i.e. stable, improving or worsening etc.,) made clear? Is the treatment or management specified? A list of problems isn’t enough. Look to the General Principles of Medical Record Documtention found in the federal documentation guidelines. Some relevant excerpts:

The documentation of each patient encounter should include:

The reason for the encounter and relevant history,

physical examination findings and prior diagnostic test results,

The patient’s progress, response to and changes in treatment and 

revision of diagnosis.

Note that these requirements are more specific than what it says in CPT: it requires a relevant history, and spells out some elements in the A/P that need to be documented for all encounters regardless of code type.

The 1997 guideline variance in the history area specifically outlined the “status of three or more chronic problems” as a way to deal with chronic disease management in the HPI.

There is another reason to provide a decent HPI. If the note consists solely of the exam and A/P, how do we know whether the A/P covers the needed ground-is complete or perhaps has superfluous issues included. 

The HPI sets the agenda for the visit. Even if the A/P areas do a good job on spelling out the problems - we need an HPI to provide the context for the A/P. You’ll see this in charts where there are two problems mentioned in the HPI, but a third and sometimes a fourth appear in the A/P. This raises the question of “mentioned” versus “managed.” 

Were all these problems actually managed today or just mentioned? If the scope of the visit is defined in the HPI, this wouldn’t happen. You should strive for a balance of HPI and A/P on the chronic disease follow up visits for a clear and easily understood encounter.

Q: Is there an actual Medicare guideline that says all the information needs to be in the body of the note? I have searched and searched and although a lot of websites say that, I am unable to locate the actual guideline from Medicare. Any help?

A: There is nothing that says that exactly that I know of. But go to the 1997 federal documentation guidelines. Within the guidelines go to the History section-the first italicized section-this refers to referencing other information. 

Q: We have been successfully doing chronic care management using 99490 code. However, a few secondary insurance companies won’t pay the copayment. The explanations of denials include: “this service is not covered”  and “this amount …not allowed due to clinical review of the appropriateness or necessity of this service” and “this service is not a benefit of federal employee program.”

I don’t understand- Medicare approves and pays their 80% of the 99490 service. How can a co-insurance deny the co-payment once Medicare has approved it?

A: This is becoming a rather familiar story. First of all, each of those secondary payers still has their own set of coverage and billing policies. Just because Medicare covers something doesn’t guarantee that a secondary payer will.

So each of those denial descriptions you’ve mentioned may mean exactly what they say.

A second potential issue here is that Medicare just started covering these services. At the time of your question we are still early in the year. It is entirely possible that some of these payers haven’t updated their edits or policies to reflect the recent change in federal coverage.

Some calls to the payer to check on coverage are in order. Remember that a first-round denial is not the final answer, it is the opening of the dialogue.