Otolaryngology Coding Alert

Stay informed and compliant to avoid this documentation pitfall. 

The switch from paper to electronic has been fundamental in the way practices streamline electronic health record (EHR) processes. But this “ease of use” factor has left some offices susceptible to fraudulent practices.

That’s because EHRs opened the door to practices using variations of the same patient chart, otherwise known as chart “templates.” These templates can include health records that are similar — or even identical — among varying patients and encounters. Payers are increasingly on the lookout for these sorts of red flags.

“It’s becoming an issue that you could potentially see costing you a recoupment in your practice,” says Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA, owner of Terry Fletcher Consulting Inc. and consultant, auditor, educator, author, and podcaster at Code Cast in Laguna Niguel, California.

Plus, if you’re not careful, you could get an intentional fraud audit, she says.

Records Should Reflect Reality

Cloned notes are becoming an increasingly significant issue between providers and payers, with payers and Medicare Administrative Contractors (MACs) releasing directives reminding providers that while some diagnoses may be similar between patients, there’s probably a slim chance that different patients had the exact same signs, symptoms, and received the same services during an encounter.

Watch out, too, for overdocumentation, which involves tweaking the medical record or your claim to bill for more services than your physician actually performed.

Payers contend that the practice of using cloned notes and submitting these as documentation for payment for services rendered, whether intentional or unintentional, does not meet the threshold of medical necessity, and could set up the provider for problems down the road, such as audits.

Be Careful About Software Ease of Use

Payers and MACs are zeroing in on practices whose patients’ records may not be accurate because they’ve been copied.

“When there’s no varied information, when they don’t see it change, or when they start to ask to audit or ask for records from different payers from the same provider or group practice, they’re looking to see if that same language is put into that same record,” Fletcher says.

The software may make the documentation easier, especially by suggesting signs and symptoms that frequently correlate with a diagnosis, but you and your employees should know to avoid any temptation to cut and paste.

“Obviously, if you use the same medical software, you’re going to have a lot of similarities; but they’re looking for cloned, meaning the exact same thing for different patients for the exact type of medical record of what’s being submitted, and that’s where it becomes a problem,” Fletcher adds.

Software Can Also Complicate Your Documentation Best Practices

“Some [Promoting Interoperability] PI Programs’ technologies auto-populate fields when using templates built into the system. Other systems generate extensive documentation on the basis of a single click of a checkbox, which if not appropriately edited by the provider may be inaccurate. Such features produce information suggesting the practitioner performed more comprehensive services than were actually rendered,” says Part B MAC Palmetto GBA.

Document Only Authentic Information

Besides being scared about reimbursement issues and fraud audits, you should be motivated to ensure accurate documentation for each patient and each patient encounter so that the future of the patient’s care is unblemished.

“It’s inappropriate to perform clone note documentation, because it not only can damage the trustworthiness and integrity of the record for patient care, but now you’re dealing with safety,” Fletcher says.

For example, inaccurate information in the patient’s medical record — perhaps lifted from another encounter with the same diagnosis or automatically populated by your software’s template — can lead to care decisions that are dangerous for that patient.

Patients’ medical records follow them, and with the electronic systems now in place, the records can often be accessed by multiple clinicians within a larger provider network. With the expanse of some of these networks, providers can no longer rely on the experiential context of remembering a particular patient’s history or last visit.

All providers must, instead, look to the medical record and hope that the documentation is accurate. When reviewing the medical record, one should see how the assessment and plan was developed from the history and exam. Many times, that connection of the assessment and plan is not present to the history and/or exam because of cloning or automatic population. Care must be taken to ensure that the record and the conclusions make sense.