Medical Billing Specialists Should Watch Cut and Paste Issue

Cloned health care records jeopardize Medicare payment.

The word is official: Medical billers, coders, data entry staff, or other users of EHRs (Electronic Health Records) of the pitfalls of cloning medical history information, now it has become more official. The ability to carry forward previous clinical information into the latest visit note an explicit feature of some EHRs is often referred to as cloning. The problem lies in copying forward old information, such as patient complaints from an earlier visit that have resolved themselves or old blood pressure readings. The process is known as “copy cat charting.”

At some point, EHR efficiency crosses the line into EHR abuse, as illustrated in an article on cloned documentation published in The Rheumatologist, a house organ of the American College of Rheumatology. In a follow-up visit for her arthritis, a 65-year-old woman reports that a new medication gave her diarrhea and stomach cramps. The doctor switched the woman to a new medication. During her next visit, in which the woman did not complain of diarrhea or stomach cramps, Dr. Brown pulled forward the note from the previous visit, but neglected to delete the references to diarrhea and stomach cramps. The woman’s condition, therefore on the record – looks worse than it actually is.

Because more active diagnoses for a visit can help justify a higher and more lucrative level of E/M services (more worthy of Current Procedural Terminology code 99214 than 99213, for example), this example of cloned documentation could result in a Medicare overpayment. It is more likely to happen if the EHR automatically suggests an E/M code based on the entered data.

Earlier this month, a Medicare Administrative Contractor (MAC) called National Government Services (NGS) in Indianapolis, Indiana, announced that it would recoup payment for Medicare claims if an audit uncovered cloned 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,” NGS said in a web site posting.

Michael Davis, a manager of provider outreach and education at NGS, stated that cloned documentation has been on the company’s radar since the advent of EHRs. However, it has increasingly become an issue as EHR technology goes mainstream. He chalks up this documentation misdeed not to fraudulent intent but to hectic physician schedules.

“It’s very busy for providers,” said Davis, whose MAC processes Medicare Part B claims for clinicians in New York and Connecticut. “It seems simple to cut and paste. It saves time. But the chart note does not demonstrate the unique care that each patient receives.”

OIG Work Plan for 2012 Targets Copycat Charts