Wiki Duplicate notes for two kids at same appt?

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ljhaley@gmail.com

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Hello! I have a provider who saw two children @ the same time, for the same issue (chronic low grade fevers) which ended up just being viral, no scripts, labs, no action required.
The provider said they "spent over 30 min" on this visit and wants to:
1. bill a 99214 for both kids visit based on time (not a 14 based on anything BUT time in this case)
2. Is trying to use the same IDENTICLE note for each child (Exact copy, right down to vitals taken!)
I don't think this is acceptable, since it's more of a "split time" over two patients- 99213 for each maybe?
I am more disturbed by the duplication of the note, esp vitals, etc. What can I use/refer to when approaching the provider about this? suggestions? Thank you.
 
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4. Cloning—This practice involves copying and pasting previously recorded information from a prior note into a new note, and it is a problem in health care institutions that is not broadly addressed. [16, 17] For example, features like auto-fill and auto-prompts can facilitate and improve provider documentation,but they can also be misused. The medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter. Simply changing the date on the EHR without reflecting what occurred during the actual visit is not acceptable. Using electronic signatures or a personal identification number may help deter some of the possible fraud, waste, and abuse that can occur with increased use of EHRs. [18] In its 2013 work plan, the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG) indicated that due to the growing problem of cloning, its staff would be paying close attention to EHR cloning. [19, 20]



• Cloning– Copying and pasting or otherwise duplicating information from one source to another within EHR software

 
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Oh boy.

I would expect some parts of the note to be substantially similar for 2 children of the same family being evaluated for the same problem. Would the family history match? Sure. Would the assessment be pretty similar? Sure.

The same vitals would be a red flag to me. Amy gave some good links to start with about cloning medical records.

Also, I agree with you about the time based coding. The doctor hasn't distinguished the specific time for each patient. The level would have to be calculated based on the MDM for the visit.
 
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your provider should listen to what you are saying, do what you tell them, thank you for keeping them out of jail, & give you a raise!! cloning is a great way to get yourself in trouble- & the coder is not the one that will be in trouble either!!
 
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THANK YOU EVERYONE!! Everything you said is what I was thinking! I even went to the practice administrator as this provider is a new hire coming in with some bad habits. EEK!
Thanks for backing me up and for the excellent cloning resource to have in hand- I had a few at the ready but yours is perfect! Most of the Cloning articles address using it from one patient to another, but this provider seems to think it's "normal & acceptable" for families of multiple-there's a new twist...but still not ok! Thanks again!
 
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