General Surgery Coding Alert

Identical claims could trigger fraud audit.

Even though your electronic health (medical) records (EHR or EMR) software grants you timesaving features like autofill and templates, you better use those features judiciously. Payers are on the lookout for cloned notes or health records that are overly similar (or exactly similar) among patients and reports.

“It’s becoming an issue that you could potentially see costing you a recoupment in your practice,” says Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA, owner of Terry Fletcher Consulting Inc. and consultant, auditor, educator, author, and podcaster at Code Cast, in Laguna Niguel, California.

Plus, if you’re not careful, you could get an intentional fraud audit, she says.

Document Only Authentic Information

Cloned notes are on payers’ radar screens, with Medicare Administrative Contractors (MACs) releasing directives reminding providers that using cloned notes and submitting these as documentation for payment for services, whether intentional or unintentional, does not meet the threshold of medical necessity.

Part B MAC Palmetto GBA example: “Some [Promoting Interoperability] PI Programs’ technologies auto-populate fields when using templates built into the system. Other systems generate extensive documentation on the basis of a single click of a checkbox, which if not appropriately edited by the provider may be inaccurate. Such features produce information suggesting the practitioner performed more comprehensive services than were actually rendered.”

More software temptations: If your software suggests signs and symptoms that frequently correlate with a diagnosis, you should avoid any temptation to cut and paste. You must document what your surgeon identifies as the presenting symptoms and the final diagnosis rendered from clinical evidence and possibly a final pathology report.

“Obviously, if you use the same medical software, you’re going to have a lot of similarities; but, [payers are] looking for cloned, meaning the exact same thing for different patients for the exact type of medical record of what’s being submitted, and that’s where it becomes a problem,” Fletcher adds.

Focus on Patient Safety

Besides concerns about reimbursement issues and fraud audits, you should be motivated to capture accurate documentation to ensure suitable patient care.

“It’s inappropriate to perform clone note documentation, because it not only can damage the trustworthiness and integrity of the record for patient care, but now you’re also dealing with safety,” Fletcher says.

For example: Inaccurate information in the patient’s medical record — perhaps lifted from another encounter with the same diagnosis or automatically populated by your software’s template — can lead to care decisions that are dangerous for that patient.

Patients’ medical records follow them, and multiple clinicians within a larger provider network have access. All providers must look to the medical record and hope that the documentation is accurate.

Implement Documentation Best Practices

Simply avoiding the cloning pitfall won’t ensure that your surgeons provide quality documentation.

To accomplish the best medical record for optimum patient care and payment, make sure your surgeons’ notes meet the following criteria:

• Reliability: The documentation should support the rationale for the diagnosis and medical necessity for the procedure. If it doesn’t, you should question the reliability of the note and ask the surgeon for clarification. Most denials occur when at least part of the documentation doesn’t support the codes you report.
• Precision: Clinical documentation must be exact, and strictly defined. Make sure your surgeon uses terms precisely, such as using “biopsy” or “resection” to describe the extent of a surgical procedure.
• Completeness: Good documentation fully addresses all necessary items, including complete patient information, procedure description, diagnosis statement, and physician identification.
• Consistency: Documentation shouldn’t be contradictory. If there are conflicting statements in the record, such as a difference between the rule-out diagnosis and the final diagnosis based on the pathology report, make sure you address them.
• Clarity: Documentation should be unambiguous. Vague op reports that don’t clearly state pertinent information such as the surgical approach or extent of a procedure could lead to unsupported claims.
• Timeliness: Documentation must be up to date to help ensure optimal patient care.