Medical record cloning: When documenting, avoid the temptation
[This quarterly column is written by Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates, Baton Rouge, LA.]
Medical record cloning is rapidly becoming a target of Medicare audits as more hospitals and medical practices move to electronic medical records (EMRs). As the health care industry has realized significant advantages from use of EMRs, documentation has drawn increasing governmental attention due to the increase in charges. In 2012, a New York Times analysis of Medicare data compiled by the American Hospital Directory found that hospitals received $1 billion more in Medicare reimbursements in 2010 than they had in 2006, at least in part by changing the billing codes assigned to emergency department visits.
The findings involved two potential abuses. One is cloning, a result of a doctor’s process of cutting and pasting information from a patient’s electronic record to suggest that the services were performed again at a later date or the use of the same documentation for other patients as well. The other potential abuse is "upcoding," in which providers exaggerate the intensity of care provided or the severity of a patient’s condition to justify higher billings.
A letter from Department of Health and Human Services (HHS) Secretary Kathleen Sebelius and U.S. Attorney General Eric Holder was sent to the American Hospital Association (AHA), three other hospital groups, and the Association of American Medical Colleges. The letter stated that while electronic health records (EHRs) improve care quality and coordination, HHS has seen "troubling indications that some providers are using this technology to game the system, possibly to obtain payments to which they are not entitled."
The letter was sent following various studies and news reports suggesting that EMR systems are contributing to a rise in upcoded and cloned bills. The Center for Public Integrity released an analysis of Medicare claims from 2001 to 2010 that showed over time, providers used higher Medicare billing codes "despite little evidence that Medicare patients as a whole are older or sicker than in past years, or that the amount of time doctors spent treating them on average was rising."
The AHA has since stated that the increased visit levels could be attributed to EMRs creating more accurate documentation that feeds more specific and accurate codes — and that not all reimbursement increases can be attributed to fraudulent practices. Regardless, the AHA said that more detailed national guidelines need to be developed for hospital emergency department and clinic visits that would simplify the "highly complex" Medicare and Medicaid payment rules.
Currently, Medicare Administrative Contractors (MACs) have increased their oversight of potential record cloning and upcoding through their audit programs and provider communications. For example, Palmetto GBA defines "cloning" as 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 EMR. While these methods of documenting are acceptable, it would not be expected that 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.
The greater problem is that Medicare and Medicaid have addressed cloned documentation as it relates to medical necessity. They do not believe that cloned records meet medical necessity requirements for coverage of services. When identified, cloned documentation may lead to denial of services for lack of medical necessity and recoupment of all overpayments made.
Prior to EMRs, templates were widely used for handwritten records and allowed physicians to document comprehensive visit information in a fraction of the time required for fully handwritten charts. With EMRs, templates may also be used to record details of a visit by establishing standard elements of the history and physical examination. For example, when the physician checks "normal" for the GI system, the EMR system may automatically fill in other descriptors such as "abdomen soft" and "normal bowel sounds," etc. If the physician did not actually listen to the patient’s bowels with a stethoscope, this potentially puts the provider at risk for issues related to payment as well as quality and legal issues.
Another problem with the EMR automatically filling in documentation for services that weren’t performed is that it may lead to "over-documentation" and selection and billing of a higher E/M code than medically reasonable and necessary. A comprehensive history and physical examination for a patient with minimal risk factors and low acuity complaints could be perceived as over-documentation leading to upcoding. One could argue, however, that in the emergency department setting, patients and their problems are new to the ED physician, and comprehensive H&Ps are necessary to assure the patient has no additional underlying medical problems or complications that may affect treatment, even for a perceived "minor" problem.
Consider what these template statements express:
• "I personally reviewed the database, confirming and supplementing the data while obtaining the patient’s comprehensive history from history source if other than the patient."
• "I have personally supervised the services provided to this patient by the resident and/or NPP and agree with all entries."
• "I have examined this patient and supervised the resident/PA during personal performance of all listed history and physical examination services."
• For male patients, "LMP as listed, neg for pregnancy."
Why does "over-documenting" matter? The Social Security Act, section 1862 (a)(1)(A) states: "No payment will be made ... for items or services ... not reasonable and necessary for the diagnosis or treatment of an injury or illness or to improve the functioning of a malformed body member." This is the overarching criterion for determining medical necessity for Medicare. Word processing software, EMRs, voice recognition software, and templated records contribute to the cut and paste of medical information. Information that is not pertinent is not considered medically necessary for the visit or problem.
Documentation supporting services performed by residents and non-physician practitioners is especially vulnerable. Recovery Audit Contractors (RACs) continue to identify cloned documentation when the attending physician cuts and pastes from the resident’s note or the non-physician practitioner’s notes into his or her own or uses canned notes that are not specific to the patient. Centers for Medicare and Medicare Services (CMS) requires personalized documentation of each encounter so that the note stands on its own and represents the services personally provided by the attending physician for each date of service or encounter.
MACs that audit charts for medical necessity have been directed by the CMS to identify "suspected fraud, including inappropriate copying of health information" under the Benefit Integrity/Medical Review Determinations mandate.
All documentation in the medical record must be specific to the patient and his or her 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.
Consider these documentation tips to avoid cloning issues:
• Empower coders and auditors in your practice/institution to identify inappropriate cloning/template issues and meet with providers regularly to address these risk areas. It is not uncommon to find unacceptable language to support billing for services. ("Seen and agree, all systems negative, 14 point review unless indicated otherwise, etc.")
• Don’t let your electronic billing/documentation system select the codes for you. It is important to review the service provided and bill accordingly.
• Read over any cloned documentation to make sure the notes make sense for that patient and problem. The chief complaint and risk factors should carry through to the exam and history and support the decisions made within medical necessity guidelines. The ED course should support the personalized information obtained through the history, physical exam, and medical decision-making.
• Review the record before you sign each note. Your signature, whether actual, stamped, or electronic, indicates you agree with the information provided on that date of service.
• Have clinical and coding/auditing staff review any templates in your EMR in advance.
• Template the most frequently performed services but avoid a chart with no personalization or inaccurate information and assure all elements of the template statement have been performed as medically necessary.
• Watch out for the auto-populate and recall functions with EMRs. This often results in documentation errors.
• Utilize speech recognition technology carefully to personalize records for specific patient issues and improved documentation.
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