Ophthalmology and Optometry Coding Alert

Answer: The short answer is that it’s not okay to clone electronic health record (EHR) notes. This situation is loaded with compliance red flags. How can anyone anticipate what will happen in an encounter before it happens? Although cloning notes often feels like a time saver, it is unethical and can cause a lot of headaches down the road.

MACs weigh in: Several Medicare administrative contractors (MACs) have published their own opinions, stating that they consider documentation cloning 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 made, they warn.

Remember, a patient’s record, including documentation of their visits with their healthcare providers, is the narrative that informs their current and future care. Cloning or copying and pasting or otherwise not recording information accurately and honestly can skew the treatment a patient receives later in life. While a practitioner can dictate what happens during an encounter or use a scribe, the situation you’re describing is not compliant with ethical documentation.

For more information: The Centers for Medicare & Medicaid Services (CMS) website has an “Electronic Records Toolkit” that addresses specific concerns and violations regarding note cloning: https://www.cms.gov/medicare/medicaid-coordination/states/dcoumentation-matters-toolkit.