July 18, 2014
By Nancy Clark, CPC, CPB, CPMA, CPC-I
More health care providers utilize electronic health records (EHR) than ever before. In part, this is due to government incentives. As the transition from paper medical records to EHR continues, payers and auditors are noticing a problem with these records: cloning. According to Medicare,“documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment.”
An intention of EHR implementation is to simplify medical record documentation; however, caution must be taken not to over utilize the “cut and paste” or “carry forward” features. Questions are raised when documentation for complaints of allergies and severe chest pains have the exact same physical exam documented. While some aspects of an exam would be performed for both complaints, it is unlikely that the exam would be identical. Therefore, care must be taken to substantiate a significant, separate office visit.
Some providers rely on the “free text” entries to summarize their assessment. If the template associated with this visit is not modified, the resulting documentation may indicate that the “patient presents with abdominal pain.” Later in the same documentation, the review of organ systems may indicate that gastroenterological (GI) system is “negative,” meaning the patient has no abdominal complaints. This practice is seen frequently, and results from the provider not removing default entries in the standard template. From an auditor’s perspective, this decreases the authenticity of the documentation.
Additionally, Medicare has stated that it will not reimburse services when it is deemed that the documentation is cloned. The Medicare Claims Processing Manual, Chapter 12, section 30.6.1A states “Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.”
So, what is a provider to do? In an American Academy of Professional Coders’ article by Rhonda Tews, it is suggested that providers develop not one but several separate templates. Each template would be based on a level of medical decision making—low, moderate, or high—and also identify a new or established patient to the practice. The corresponding documentation of the visit would vary according to the severity of the complaint. At the very least, this is a start for more specific documentation. Additionally, templates can be created for frequent complaints, such as respiratory issues (cough, cold, flu), abdominal pain, musculoskeletal complaints, and other common reasons to seek medical attention. Templates should be created as reminders to physicians to ensure complete documentation, not to supply the context of the medical record.
It should be noted that EHRs have many valuable features, including improved efficiency, coordination of care, patient access to medical records and ease of transferring records between physicians. The latter could save lives when patients are seen by physicians outside of their primary medical office, such as in an emergent care episode out-of-state. As long as care is taken to tailor the record to the specific patient encounter, EHRs will continue to be a valuable tool in health care.