Hi All,
I am looking for some opinions regarding cloning in a patient's record. I am review several follow up visits (all documented by the same provider) with very minimal changes to the CC, HPI, and ROS. The A/P isn't very detailed to support MDM.
I'm looking to see if there is any resource I can cite that specifies that cloned documentation cannot factor into the LOS.
The provider is asking to be shown something specific, and says that the minor changes of adding and dropping a word proves that isn't cloning because he has touched the record.
I already used this resource:
Per the Centers for Medicare & Medicaid Services (CMS), “Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries” (Medicare B Update, third quarter 2006 (vol. 4, No. 3)
He is now saying he wants to see something specific that says anything that is suspected as a cloned note, the documentation, cannot factor into the E/M LOS he selects.
Any thoughts??
I am looking for some opinions regarding cloning in a patient's record. I am review several follow up visits (all documented by the same provider) with very minimal changes to the CC, HPI, and ROS. The A/P isn't very detailed to support MDM.
I'm looking to see if there is any resource I can cite that specifies that cloned documentation cannot factor into the LOS.
The provider is asking to be shown something specific, and says that the minor changes of adding and dropping a word proves that isn't cloning because he has touched the record.
I already used this resource:
Per the Centers for Medicare & Medicaid Services (CMS), “Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries” (Medicare B Update, third quarter 2006 (vol. 4, No. 3)
He is now saying he wants to see something specific that says anything that is suspected as a cloned note, the documentation, cannot factor into the E/M LOS he selects.
Any thoughts??