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Cloning Notes

by Carol Crews on August 19, 2014

Would your medical chart documentation withstand a government or commercial payor audit?

LBA assists many providers in the community by reviewing their chart documentation to ensure they are complying with carrier guidelines. One of the many challenges providers face is utilizing the electronic health record (EHR) in an efficient way that allows more time with the patient, without documentation being perceived as fraudulent billing because a template has been used or information has been copied/pasted from the patient’s previous visit.

The Office of Inspector General (OIG) stated in January that cloning of notes can be viewed as the provider’s way of falsifying information in the medical record in order to bill a higher rate, thus committing fraud. The OIG Work Plan for FY 2014 (pg. 18) states “we will determine the extent to which selected payments for evaluation and management (E/M) services were inappropriate. . . Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the billing code for the service on the basis of the content of the service and to have documentation to support the level of service reported.”

The Centers for Medicare and Medicaid Services (CMS) allows providers to use templates built in EHRs but the documentation for the visit must be specific to the patient, for the current date of service, and must accurately reflect the service rendered on that day. First Coast Service Options, the Medicare Administrative Contractor for CMS in Florida, states that “It would not be expected that every patient has the same exact problem, symptoms, and require the same exact treatment.”

The Review of Systems (ROS) or Patient Family Social History (PFSH) can be copied from a previous visit but the provider must note the date of the earlier ROS or PFSH and indicate any changes from the previous visit or systems that were not reviewed.  In addition, a template can be used for the exam, however, it should be updated to reflect the body areas or organ systems reviewed in order to do an assessment and develop a plan of care for that visit. The exam should be specific to the reason for the visit (chief complaint). Medical necessity may be in question when a template for a comprehensive exam is being used for someone presenting with a minor illness or injury, or who is being seen in follow up from a previous visit.

Copying and pasting notes from one visit to the next may allow the provider to spend more time with the patient and less time on chart documentation. Our advice to our clients is to ensure they are updating the data and are accurately capturing the assessment and plan of care pertinent to that patient for that visit.

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