# Cloning



## bethdeak (Jul 24, 2018)

Hi All,

I am looking for some opinions regarding cloning in a patient's record.  I am review several follow up visits (all documented by the same provider) with very minimal changes to the CC, HPI, and ROS.  The A/P isn't very detailed to support MDM.

I'm looking to see if there is any resource I can cite that specifies that cloned documentation cannot factor into the LOS.  

The provider is asking to be shown something specific, and says that the minor changes of adding and dropping a word proves that isn't cloning because he has touched the record.

I already used this resource:

Per the Centers for Medicare & Medicaid Services (CMS), “Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries” (Medicare B Update, third quarter 2006 (vol. 4, No. 3)

He is now saying he wants to see something specific that says anything that is suspected as a cloned note, the documentation, cannot factor into the E/M LOS he selects.

Any thoughts??


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## thomas7331 (Jul 24, 2018)

In my opinion, 'cloning' is a documentation quality issue, not a coding issue, and should be handled separately from coding.  To my knowledge, there are no published guidelines about how cloning or the overuse of copy/paste should play a role in code choices.  And unless a coder happened to be present in the exam room with the patient and provider, there is no way for a coder to make a determination of what information in the record is valid or not.  In the context of coding, cloned records may look suspicious, but beyond that, a coder has no way to know with any certainty what elements they should start eliminating for consideration in determining an E&M level.  

Unless an organization gives internal guidance on this, I personally would recommend that coders stick to the coding guidelines and code based on what is documented.  Simply changing the coding rules because a provider may be doing something wrong is compounding a problem, not solving it.  If a provider is populating patient records with incorrect information, this poses a risk to patient care that goes beyond just billing an E&M level that is too high, so lowering the level is not the correct response.  But at the same time, certainly, coders are the 'eyes and ears' on the front lines for problems in documentation, so any issues that could affect the quality of the medical record and put a practice at risk in an audit should absolutely be escalated to management or compliance so that they can be addressed.  

The OIG and a number of professional societies have recommended that provider organizations create internal policies to monitor documentation quality and take steps to ensure that the electronic tools available to providers are not used inappropriately.  In my opinion, this is the proper way to address this issue - not by changing E&M levels, which is arbitrary and also does not get to the root cause of the problem.


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## Pam Brooks (Jul 24, 2018)

Neither CMS or the OIG have clearly said you cannot use cloned documentation to support E&M documentation guidelines.  Essentially, all that has been said about cloning is that the risk of misuse of EHR records through cloning may cause the OIG (in their 2013 workplan) to take a 'closer look'.  

Some contractors however, have indicated that "cloned documentation does not meet medical necessity for coverage of services". (Palmetto GBA). National Government Services says, "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."  

We  do know that "medical necessity is the overarching criteria for code selection" (that is in the 95 and 97 guidelines).  It would seem reasonable then, that cloned documentation may not be used to support any given visit where medical necessity is required.  However,  I've yet to see an audit of my records specifically for cloning trends, or a recoupment request for the same, but I'm willing to be that payers are looking at those cloning trends  when they request records for other reasons.  It's just impossible to tell based on claims data alone.    
Here's the link to the short article:  

https://www.palmettogba.com/palmett...care~EM Help Center~Medical Review~8MKQK88358

Auditors and consultants alike agree that cloning of documentation is subject to all sorts of errors and inaccuracies, and many of them recommend that internal policies be put in place to limit or validate certain types of cloning.  It still is the responsibility of the physician who authors the electronic medical record to validate and authenticate that all elements of the patient note are accurate.  Until CMS comes up with a clear and all-inclusive rule, policy or guideline that specifically prohibits cloned records, it is up to coders and auditors to educate providers on the need to be cautious and conscientious about the use of pull-through, cut/paste,  or cloning technology in the patient's medical record.  

It remains the task of coders and auditors to determine if cloned data is accurate, appropriate and medically necessary in a way that would allow it to be considered supporting documentation for the service that is being reported.


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## bethdeak (Jul 24, 2018)

Thanks for both your feedback on this.

I have been working with this provider because there are multiple issues happening.  There is the cloning across the CC/HPI/ROS and even exam. 

When we get into the assessment and plan, and the MDM it's not there.  For the assessment he is just listing ICD-10 codes,  when we get into the plan it might say 'labs ordered' but never why the labs are ordered/for what condition and sometimes 'patient given hand out' but not what the handout if for.  I don't feel it's safe to assume when 4 diagnosis are listed what is being managed when it's not clear in the MDM.


 In his mind the EMR is helping him score a level four visit because he is moving forward his notes and changing a word or two here.  He feels the more diagnosis he lists the more it's given him credit for, but I can't see anything 90% of the time to score him for what he is doing (adjusting meds/ordering tests/counseling/pt orders) because there is nothing there to support it.

Not to mention there is some resistance to the re-education !


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