Set Up Templates So Cloning Is Not Questioned
Maximize the full potential of EHR tools, but abide by the documentation rules.
By Ronda Tews, CPC, CHC, CCS-P
Electronic health records (EHRs) are supposed to save providers time and improve the quality and legibility of their documentation. Another hoped-for advantage of EHRs is better patient care. EHRs are not intended to increase the quantity of documentation solely to support billing higher-level evaluation and management (E/M) services. The Medicare Claims Processing Manual (Chapter 12, section 30.6.A) states, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.”
Avoid Copy and Paste Abuse
Technology can improve efficiency, but ease of use can lead to abuse of certain electronic functions, such as the Copy and Paste commands. The ability to copy and paste content in an EHR saves time, in that you don’t have to retype the same information. Trouble ensues, however, when the functions are used inappropriately to repurpose complete notes from one date of service to another or from one record to another. This is known as cloning, which the Centers for Medicare & Medicaid Services (CMS) considers to be a form of abuse.
Medicare B Update, third quarter 2006 (vol. 4, no. 3) states:
Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment.
Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.
On September 24, 2012, Kathleen Sebelius, then secretary of the U.S. Department of Health & Human Services (HHS), and Eric Holder, attorney general of the Department of Justice (DOJ), issued a joint letter to five hospital associations. The letter cited possible abuses, including cloning of medical records. Specifically, the letter said there were, “reports that some hospitals may be using electronic health records to facilitate ‘upcoding’ of the intensity of care or severity of patients’ condition as a means to profit with no commensurate improvement in the quality of care.” The letter continued, “There are troubling indications that some providers are using this technology to game the system, possibly to obtain payments to which they are not entitled. False documentation of care is not just bad patient care; it’s illegal.”
Each patient encounter should be distinct and separately identifiable from other patient encounters, so that no two look exactly alike. For this reason, it’s not a good idea to regularly use the copy and paste functions. It also isn’t a good idea to use the same template for every patient encounter.
Customize Your Templates
Many providers have created one template that includes a comprehensive history, with a complete review of systems (ROS), and a comprehensive exam, and they use this template for all of their patients—whether a patient presents with a sore throat or chest pain. The result is often notes that look alike, and that are not based on the patient’s presenting problem or the medical necessity of the visit. This raises all sorts of red flags for auditors to see. An auditor may question, for example, why a patient with a sore throat needed to have a complete ROS done when the medical decision making (MDM) was of low complexity—and rightly so.
Because MDM should be the main factor in determining the level of E/M service, I recommend building one template for each level of MDM (low, moderate, and high complexity). Usually, a provider has a general idea of the level of service he or she plans to bill based on the reason the patient is being seen. For example: If an established patient presents for a sore throat and fever, the provider can assume it will be a level 3 visit, and bring up an “established, moderate” template. This will allow the notes to be more specific and varied, lessening the risk for cloning.
The bottom line: To maximize the full potential of EHRs and abide by the documentation rules, take a little time to set up individual templates to cover the various E/M levels, instead of relying on one template to cover all patients.
Ronda Tews, CPC, CHC, CCS-P, is system integration manager for Mercy in Oklahoma City, Okla. She oversees the EHR team, which assists new clinics and new providers in EHR implementation and creates templates for providers. Tews’ previous duties with Mercy include establishing internal auditing and monitoring, teaching basic coding classes to coworkers, and providing E/M documentation training to physicians and midlevel providers. She has been in the healthcare industry for over 20 years, and has served as secretary and president for the local Springfield, Mo., local chapter.