Wiki Help!!!! - I code for a cardio doctor

[mama2stephen]

I code for a cardio doctor who has in his electronic note that a patient has "hypertension for 5 years" and it says that in every note from the previous years. I think it needs to be changed each year, but other coders don't really see a issue with it. Any input on this issue would be greatly appreciated.

Thanks!!!

 

[dclark7]

This is an example of one issue with electronic medical records the same information is carried over from note to note. CMS considers this cloned documentation (it is the same in every note) and they will be looking for these types of things. In August of this year NGS sent out a notice stating that "....cloned documentation would be considered a misrepresentation of the medical necessity requirement for coverage of services...."

I agree with you, this should be updated periodically or the statement should be in the patient history as "Hypertension diagnosed in XXXX".

 

[MnTwins29]

Amazing!

As I was reading this thread, my SVP sent me an email with the statement from NGS. Here it is in its entirety:

Cloned Documentation Could Result in Medicare Denials for Payment
Medicare providers today are faced with the challenges of providing quality healthcare while meeting ever increasing regulatory and compliance regulations. Many providers are investing in Electronic Health Records to increase the quality of their documentation, decrease or minimize documentation time and improve their overall record keeping capabilities. However, providers need to be aware that Electronic Medical Records can inadvertently cause some documentation pitfalls such as making the documentation appear cloned. Cloned documentation could cause payment to be denied in the event of a medical review audit of records.

Documentation is considered cloned when it is worded exactly like or similar to previous entries. It can also occur when the documentation is exactly the same from patient to patient. Individualized patient notes for each patient encounter are required. Documentation must reflect the patient condition necessitating treatment, the treatment rendered and if applicable the overall progress of the patient to demonstrate medical necessity.

An Electronic Health Record often allows the providers to utilize default options. Defaulted documentation may cause a provider to overlook significant new findings that may result in safety/quality issues. Default data may document a more extensive history and physical exam than is medically necessary and does not differentiate new findings or changes in a patient's condition. When documenting a service such as spinal manipulation therapy (SMT), it is important to document the progress of the patient. Defaulted or cloned documentation also applies to other disciplines where the documentation must demonstrate that the patient is making progress towards treatment goals, or documenting the patient's findings or changes in a patient's condition to meet for Medicare medical necessity.

Whether the documentation was the result of an Electronic Health Record, or the use of a pre-printed template, or handwritten documentation, cloned documentation will be considered misrepresentation of the medical necessity requirement for coverage of services due to the lack of specific individual information for each unique patient. Identification of this type of documentation will lead to denial of services for lack of medical necessity and the recoupment of all overpayments made.

Last Modified: 9/5/12


SOURCE:
http://www.ngsmedicare.com/wps/port...GION&LOB=Part B&digest=N_5daMHgbyRiOPvt7gua6g

 

[mama2stephen]

Thank y'all so much!!!