Results 1 to 4 of 4

EHR cloning

  1. #1
    Default EHR cloning
    Medical Coding Books
    The Dr. does an office visit on 09/01 and admitts the same patient on 09/10.
    The notes are identical except for 2 items in the plan and impression for 09/10
    My take on this is that the cloned note on 09/10 cannot be used because that exact information was already used on 09/01.
    may I get some feed back on this ?
    thank you

  2. #2
    Location
    Austin, Texas
    Posts
    467
    Default
    Quote Originally Posted by JCARPENTE View Post
    The Dr. does an office visit on 09/01 and admitts the same patient on 09/10.
    The notes are identical except for 2 items in the plan and impression for 09/10
    My take on this is that the cloned note on 09/10 cannot be used because that exact information was already used on 09/01.
    may I get some feed back on this ?
    thank you
    This is the crux of the problem. EHR is supposed to make a provider's job easier for documentation. However, when the HPI/physical exam/notes/ROS/etc is the same as a prior visit, then auditors/payers/coders have an issue because the provider "clones" or copies or templates the prior information which then creates a visit that "looks" like the provider did not do a thorough evaluation, when in fact he most likely did. So now the auditors/payers don't want to pay the provider. Does the provider now change the wording on each encounter just so he is not accused of cloning? This defeats the specific intent and purpose of EHR.
    Marcus Murphy, CPPM

  3. #3
    Location
    Monroe, NC
    Posts
    47
    Default
    Actually I review medical records for a living and I disagree. I have personal experience with cloning. It is detrimental to the record and I am glad cms is cracking down on it.

  4. #4
    Location
    Daytona Beach, FL
    Posts
    752
    Default
    This is the crux of the problem. EHR is supposed to make a provider's job easier for documentation. However, when the HPI/physical exam/notes/ROS/etc is the same as a prior visit, then auditors/payers/coders have an issue because the provider "clones" or copies or templates the prior information which then creates a visit that "looks" like the provider did not do a thorough evaluation, when in fact he most likely did. So now the auditors/payers don't want to pay the provider. Does the provider now change the wording on each encounter just so he is not accused of cloning? This defeats the specific intent and purpose of EHR.
    I have a similar issue with my providers. The EHR allows them to "clone" the HPI, ROS, PFSH and Exam from the previous visits. The carried forward documentation is not appropriate for the current visit - i.e. "Pt here for chest pain for the past 2 weeks" on the first visit, then on the 2 month f/u visit it states "Pt here for chest pain for the past 2 weeks" with a statement of "no sob or chest pain" added. How is this appropriate? Yes the provider needs to change the wording on each encounter to reflect what has been happening between the last encounter and this encounter. I really do not think that the intent or purpose of the EHR was to plagerize from a previous visit. This is not appropriate for good patient care and should not be allowed! Also, just because the doctor has cut and pasted an exam from the last visit, does not mean that he did that same exact exam with the same exact results! Again, my doctors bring forward the last exam from the previous visit no matter what the patient is here for...they are here 2 weeks after their initial visit to go over test results. This does not warrant a detailed exam, however they cloned the previous exam and this makes it appear that they did more work than I am sure they must have done - or needed to do based on medical necessity. I am working on getting this issue stopped in my practices and I think that it is good that CMS is cracking down on it. The EHR companies really need to rethink how their programs work and create a product that can be used correctly and in compliance with CMS guidelines!
    Jodi Dibble, CPC

Similar Threads

  1. Diagnosis "Cloning"
    By dorinda05 in forum Diagnosis Coding
    Replies: 3
    Last Post: 07-30-2015, 12:51 PM
  2. Cloning and templates
    By jdibble in forum EMR/EHR Systems
    Replies: 6
    Last Post: 08-21-2014, 11:47 AM
  3. Doc Cloning or Not??????
    By HAPPYCODER in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 01-30-2014, 11:57 AM
  4. EMR Documentation Cloning
    By mobrien in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 04-16-2008, 06:10 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.