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Tips for Billing Success: Cloned Documentation

Electronic health records (EHRs) offer many time-saving advantages and provide an effective

June 14, 2018
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Electronic health records (EHRs) offer many time-saving advantages and provide an effective communication tool for providers. With the ease and frequency of EHR use come the disadvantages of cloning, also known as “cutting-and-pasting.” This practice involves copying information from a prior note into a new note. Software features such as templates, macros, auto-fill, and auto-generated prompts can be misused while the provider completes the documentation.

Medical records must contain documentation showing the needs of each patient during each encounter. It is unacceptable to import previous documentation and change the date on the EHR without reflecting new developments in the patient’s care and status.

Record Differentiation

In a lower-back injury case, the initial office visit note indicated that the worker slipped and fell on ice. She suffered pain with a severity level of four to six from a lower-back strain, which was worsening throughout the day. Two weeks later, the patient returned for a follow-up visit, and the history of the present illness (HPI) was cut-and-pasted from the initial date of service.

Although the diagnosis of lower-back strain had been determined, the history of present illness (HPI) is different from the initial assessment because the pain level was decreasing and physical therapy had helped to improve her range of motion. It may be appropriate to include past history from the injury, but the documentation for the return visit must accurately reflect what is happening during the current office visit.

The following details help reflect that patient’s status:

  • Is the patient’s pain worsening, improving, or staying the same?
  • Are there additional complications that were not present at the onset of injury?
  • Is there a new injury or exacerbation of the current injury?
  • If the patient has started therapy, has it improved the patient’s condition?

The review of systems is another documentation problem area when the record reflects a statement such as “all systems negative” when the patient presents with a fracture or new symptom.

Documentation of the medical decision-making can also be cloned when the record reads “patient medication reviewed, continue as prescribed.” It is not clear whether the medications were reviewed or the documentation was copied from a previous visit.

Implications of Cloning

Cloned information contributes to "documentation overload," or "note bloat," which makes it difficult for providers to pick out pertinent information that may be lost in redundant notes. Services that were administered during the prior office visit may not have been medically necessary or even delivered in the return visit.

In addition, determining the level of a visit for billing and coding purposes includes the patient's presenting problem on the day of the visit. Redundant documentation lacks pertinent information that helps a provider determine whether the patient is progressing as expected. If the patient is experiencing complications or worsening of the condition, a higher-level visit with more extensive services may be warranted.

The U.S. Department of Health and Human Services, Office of the Inspector General (HHS-OIG) is critical of documentation cloning. In its work plan, the HHS-OIG stated it will be paying close attention to cloning, as it may contribute to inflated, duplicate or fraudulent billing claims. The HHS-OIG is concerned that EHRs may auto-populate fields to meet reimbursement requirements and that the practitioner performed more comprehensive services than were actually rendered.

Importing information from a prior visit may ease the administrative burden of documentation for providers, but caution is advised if the documentation does not reflect the specific patient status and services rendered during the current visit.

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