Pulmonology Coding Alert

Question: In auditing our physicians’ documentation in our EMR system, I’m seeing a pattern: Multiple physicians are using the same phrase, “skin- warm and dry” and this appears to be a copy and paste. I understand that CMS does not permit this and that it violates correct coding guidelines. Can you help me confirm this and direct me to rules on the Medicare/CMS web site?

Codify Subscriber

Answer: You’re right to raise concern about this documentation duplication, also known as “cloning.” Each examination your physicians perform is meant to paint a clear picture of the individual findings for each encounter. It is not appropriate to clone an entire examination from visit to visit.

There are cases, however, where a template will be used within the EHR, and that could be what you are seeing in the providers’ documentation. Be sure to double check to see if templates are being used.  

Risky features: CMS says in its Electronic Health Records Provider Fact Sheet that cloning can result from EHR features “like auto-fill and auto-prompts,” which, while improving provider documentation, “can also be misused.”

The agency maintains that “the medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter. Simply changing the date on the EHR without reflecting what occurred during the actual visit is not acceptable.”

Precaution: CMS suggests in the fact sheet that using electronic signatures or a personal identification number may help deter some of the possible fraud, waste, and abuse that can occur with increased use of EHRs.

Resource: To read the CMS fact sheet on EHRs, go to https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/docmatters-ehr-providerfactsheet.pdf.