EHR templates

bsuse

Contributor
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Claremont, NH
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our clinic offices use templates extensively. the problem is the docs have them pre-filled with all the answers and they are pulled into the record long before the patient is due in the office. i cannot find any solid documentation to give to them to prevent this very bad habit of the pre-filled information. does anyone have ANY guidelines i can use to persuade them from this practice??

thanks
barb
 

squishy

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Go to the OIG website. "Cloning" and "Cut and Pasting" is on their worklist for Audits. They are looking at this especially for EHRs. Claims can be denied if they see a pattern of this.
 

00065563

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I have been searching the OIG website using "cut and paste" and "clone" for searches, and I have not found anything. Can you state specifically, where you found this?
 

Pam Brooks

True Blue
Local Chapter Officer
NAB Member
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South Berwick, ME
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HHS OIG Work Plan | FY 2013 Part VII: Other HHS-Related Reviews
Fraud Vulnerabilities Presented by Electronic Health Records
We will identify fraud and abuse vulnerabilities in electronic health records (EHR) systems as articulated
in literature and by experts and determine how certified EHR systems address these vulnerabilities. The
Health Information Technology for Economic and Clinical Health Act provides $36 billion in incentives for
adopting EHRs. Medicare and Medicaid EHR incentive programs require providers to use EHR systems
that have been certified by a Department-authorized testing and certification body. The Office of the
National Coordinator establishes the requirements and oversees the certification process. Regulations at
45 CFR part 170 provide the initial set of standards, implementation specifications, and certification

criteria for EHR systems.
(OEI; 01-11-00570; expected issue date FY 2012; work in progress)
Evaluation and Management Services—Potentially Inappropriate Payments in 2010
We will determine the extent to which CMS made potentially inappropriate payments for E/M services in
2010 and the consistency of E/M medical review determinations. We will also review multiple E/M
services for the same providers and beneficiaries to identify electronic health records (EHR)
documentation practices associated with potentially improper payments. Medicare contractors have
noted an increased frequency of medical records with identical documentation across services.
Medicare requires providers to select the code for the service on the basis of the content of the service


and have documentation to support the level of service reported. (CMS's
Medicare Claims Processing
Manual

, Pub. No. 100-04, ch. 12, § 30.6.1.) (OEI; 04-10-00181; 04-10-00182; expected issue date: FY 2013;
work in progress)


 
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Look to the Medicare Integrity Program Manual Chapter 3 Section 3.3.2.1.1

"Some templates provide limited options and/or space for the collection of information such as by using “check boxes,” predefined answers, limited space to enter information, etc. CMS discourages the use of such templates. Claim review experience shows that that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met.
Physician/LCMPs should be aware that templates designed to gather selected information focused primarily for reimbursement purposes are often insufficient to demonstrate that all coverage and coding requirements are met. This is often because these documents generally do not provide sufficient information to adequately show that the medical necessity criteria for the item/service are met."
 
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