Otolaryngology Coding Alert

Hint: Ensure that information isn’t being cloned between patient visits.

Last month we shared three important tips for ensuring compliant documentation (authentication, timing, and making alterations). Complete your list of checkpoints with two more bits of advice from Marsha S. Diamond, CPC, CPC-H, CCS, coding textbook author and past AAPC National Advisory Board member and past Greater Orlando (FL) AAPC Chapter President in the Audioeducator.com audioconference “Compliance: It’s Not Just About Coding.”

Get Familiar With Scribe Rules

If a nurse or non-physician practitioner (NPP), such as a physician assistant (PA) or nurse practitioner (NP), acts as a “scribe” for the provider, the individual writing the note or entry in the record should note “written by (name of NPP), acting as a scribe for Dr. (physician name).”

The physician should then co-sign and date the record, and also indicate that the note accurately reflects work and decisions he made during the encounter.

“It would be inappropriate for an employee of the physician to make rounds or see patients at one time and make entries in the record and then the provider make rounds later and note ‘agree with above,’ unless the employee is a licensed, certified provider (NP/PA) billing for services under his/her own name/number,” Diamond says.

Be Aware of Potential EMR Pitfalls

With the introduction of electronic medical records (EMRs) the capability of “carry over,” repetitive “fill ins,” and cloning has become prevalent, Diamond says.

Remind your providers — and coding/billing staff — that only medically necessary information is considered when you are deciding on the code to bill based on supporting documentation.

Copy and paste, cloning, and the act of carrying information forward from another record or another portion of the record has the same effect on the integrity of the medical record. Eventually, there will be contradictions in a patient’s record. Payers obviously frown on this type of documentation.

Example: First Coast Service Options, the MAC in Florida, prohibited the practice of cloning in its 2006 Medicare Part B newsletter (http://medicare.fcso.com/Publications_A/2006/138374.pdf), which states “Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment.”

First Coast further states that discovery of this type of documentation will “result in denial of services for lack of medical necessity and recoupment of all overpayments made.”

Bottom line: Cloning of documentation is considered a misrepresentation of medical necessity requirement for coverage of services. Credibility of the record is compromised and an auditor will be unable to determine what is accurate and how much work was done on one visit versus another.