The use of Electronic Health Records ("EHR") can enhance the quality of the documentation, increase legibility and save clinicians valuable time. However, there are pitfalls to an EHR that have gained the attention of the Centers for Medicare and Medicaid Services ("CMS") the Office of Inspector General ("OIG"), third party payers and even consumers.
The ability to carry forward previous clinical information into the latest note is a feature of some EHRs which can lead to cloning. By copying information forward, components of the documentation begin to appear incongruent as problems from the previous visit have resolved themselves and are not pertinent to the new visit.
When a practitioner "copies," "brings forward" or utilizes auto populated templates for elements of the History of Present Illness ("HPI"), Review of Systems ("ROS") and Physical Exam, it is imperative that the practitioner read the documentation, word for word, prior to signing off on the record. This process will reduce the likelihood of inadvertently bringing forward information that is not accurate or pertinent to the patient's presenting problem/complaint. Judicious use of auto populated templates ensures that the history, exam and medical decision making components of the E&M encounter are congruent with and not over documented relative to the patient's presenting problem/complaint.
Ignoring the risks in the use of automated insertion of historical, clinical and visit documentation or using auto populated documentation components, presents concerns relative to documentation integrity and support for medical necessity.
Regulatory Background
In January of 2014, the OIG published a report regarding the degree to which CMS and its contractors have adjusted their techniques for identifying improper payments and investigating fraud in the context of the transition from paper records to the EHR. This OIG study was based on questionnaires sent to eight (8) MACs, six (6) ZPICs, and four (4) RACs. The questionnaires asked about their policies, procedures, and experiences with EHR fraud and Medicare claims. The OIG also asked about any procedures or review practices specific to EHRs.
In summary, the OIG found that "CMS and its contractors had adopted few program integrity practices specific to EHRs. Specifically, few contractors were reviewing EHRs differently from paper medical records. In addition, not all contractors reported being able to determine whether a provider had copied language or over documented in a medical record. Finally, CMS had provided limited guidance to Medicare contractors on EHR fraud vulnerabilities."The OIG recommended that "CMS should provide guidance to its contractors on detecting fraud associated with EHRs." CMS concurred with this recommendation. CMS specifically acknowledged that given its potential for use in fraud, "CMS intends to develop appropriate guidelines to ensure appropriate use of the copy paste feature in EHRs. CMS will also consider whether additional guidance and tools are needed to help detect fraud associated with EHRs." 1
In the absence of specific guidance from CMS, Medicare Administrative Contractors ("MACs") have provided the following guidance:
- Noridian Healthcare Solutions, LLC.
Cloned documentation may be handwritten, but generally occurs when using a preprinted template or an Electronic Health Record (EHR). While these methods of documenting are acceptable, it would not be expected the same patient had the same exact problem, symptoms, and required the exact same treatment or the same patient had the same problem/situation on every encounter. Cloned documentation does not meet medical necessity requirements 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. 2
Q30. What does Noridian consider to be a cloned E/M note? If a note is very similar from day to day but is accurate to what happened, is this a cloned note?
A30. In general, if only the DOS and vital signs are different, then Noridian would most likely consider it cloned. We do realize that there may not be changes day to day detailing the stability of the patient but it is important to include the details in the documentation. Medical necessity is also important here. To repeat a family and social history on visits every week or two would be considered cloning or at least not reasonable and necessary. 3
- Palmetto GBA
The word 'cloning' refers to documentation that is worded exactly like previous entries. This may also be referred to as 'cut and paste' or 'carried forward.' Cloned documentation may be handwritten, but generally occurs when using a preprinted template or an Electronic Health Record (EHR). While these methods of documenting are acceptable, it would not be expected the same patient had the same exact problem, symptoms, and required the exact same treatment or the same patient had the same problem/situation on every encounter.
Cloned documentation does not meet medical necessity requirements 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. 4
- First Coast Services Options, Inc.
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 documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made. 5
- National Government Services
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.
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. 6
SunStone's Approach
The overarching criteria from the guidance cited above, along with industry "Best Practice", stipulate that the structure of the EHR template can impact support for medical necessity and documentation integrity. To determine our formal documentation and coding protocol for record reviews in this environment, we referenced the clinical review judgment involving CMS' two outlined steps in § 3.3.1.3 from Medicare Program Integrity Manual, Chapter 3 - "Verifying Potential Errors and Taking Corrective Actions":
- The synthesis of all submitted medical record information (e.g. progress notes, diagnostic findings, medications, nursing notes, etc.) to create a longitudinal clinical picture of the patient and,
- The application of this clinical picture to the review criteria to make a reviewer determination on whether the clinical requirements in the relevant policy have been met.
In summary, while the use of templates, and/or the ability to copy forward elements can be an advantage, each patient visit should contain documentation in the medical record that is relevant and individualized to the current service.
For more information, please do not hesitate to contact Vonda Moon, Principal, at vondamoon@sunstoneconsulting.com.
- Department of Health and Human Services, Office of Inspector General, CMS And Its Contractors Have Developed Few Program Integrity Practices to Address Vulnerabilities in EHRs. January 2014.
- Noridian Healthcare Solutions, LLC. Common E/M Errors by CERT and Medical Review. Presented by: Medicare Provider Outreach and Education (POE) August 2014.
- Noridian Healthcare Solutions, LLC. Evaluation and Management Q&A.
- Palmetto GBA, LLC. Medical Record Cloning. October 31, 2014
- First Coast Service Options, Inc. Medicare AB Bulletin. Third Quarter 2006. Volume 8, Number 3.
- National Government Services, Inc. Policy Education Topics. Cloned Documentation Could Result In Medicare Denials For Payment.