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Cloned Documentation Could Result in Medicare Denials for Payment

Medicare providers today are faced with the challenges of providing quality healthcare while meeting ever increasing regulatory and compliance regulations. Many providers are investing in EHRs to increase the quality of their documentation, decrease or minimize documentation time and improve their overall record keeping capabilities. However, providers need to be aware that EMRs can inadvertently cause some documentation pitfalls such as making the documentation appear cloned. Cloned documentation could cause payment to be denied in the event of a medical review audit of records.

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.

An EHR often allows the providers to utilize default options. Defaulted documentation may cause a provider to overlook significant new findings that may result in safety/quality issues. Default data may document a more extensive history and physical exam than is medically necessary and does not differentiate new findings or changes in a patient’s condition. When documenting a service such as SMT, it is important to document the progress of the patient. Defaulted or cloned documentation also applies to other disciplines where the documentation must demonstrate that the patient is making progress towards treatment goals, or documenting the patient’s findings or changes in a patient’s condition to meet for Medicare medical necessity. An ROS and/or a PFSH obtained during an earlier encounter does not need to be recorded again if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by describing any new ROS and/or PFSH information or noting there has been no change in the information and noting the date and location of the earlier ROS and/or PFSH.

Whether the documentation was the result of an EHR, or the use of a preprinted 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.

Cloned Documentation Could Result in Medicare Denials for Payment
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