Use of cloning in electronic records
"Cloning" medical record documentation means cutting-and-pasting the information entered in the electronic medical record (EMR) from one date of service to another. It can be a useful tool in providing elements of patient history on each page of the EMR, but can also cause problems.Cloned notes may cause:
- Inability to distinguish notes from one date of service to the other
- Falsification of the medical record, since cloned notes may not pertain to visits to which they are added
- Difficulty in establishing medical necessity, which slows claims processing
- Failure to provide appropriate documentation to support a billed service, resulting in recoupment of payment
How to use cloning appropriately
Cloning may be appropriate for elements of history when these guidelines are followed.
- Don't let an EMR select the codes for you. It is important to review the service that was provided and bill accordingly.
- Read over any cloned documentation to make sure the notes make sense for that date of service. The chief complaint should carry through to the exam and history and support the decisions made and medical necessity.
- Don't used "canned" templates. They may cause problems with medical necessity. See the example below.
- Sign each note. Your signature, whether actual, stamped or electronic, indicates you agree with the information provided on that date of service.
The trouble with templates
If a clinician checks "normal" for the GI system, the EMR system may automatically fill in other descriptors such as "abdomen soft" and "normal bowel sounds", etc. If the clinician did not listen to the patient's bowels with a stethoscope, this potentially puts the office at risk for quality of care issues, malpractice, etc.
Another problem with the EMR automatically filling in documentation is that it may lead to "over-document" which leads to selecting and billing a higher E&M code than medically reasonable and necessary.
CMS/Medicare references for this section
Cloning of medical notes
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. Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered 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.
Evaluation and Management coding procedure code/diagnosis code linking
It is not enough to link the procedure code to a correct, payable ICD-10-CM code. The diagnosis or clinical signs/symptoms must be present for the procedure to be paid.
Volume of documentation vs. medical necessity
The Social Security Act, Section 1862 (a)(1)(A) states: "No payment will be made ... for items or services ... not reasonable and necessary for the diagnosis or treatment of an injury or illness or to improve the functioning of a malformed body member." This medical reasonableness and necessity standard is the overarching criterion for the payment for all services billed to Medicare. Providers frequently "over document" and consequently select and bill for a higher-level E&M code than medically reasonable and necessary. Word processing software, the electronic medical record, and formatted note systems facilitate the ...carry over... and repetitive "fill in" of stored information. Even if a "complete" note is generated, only the medically reasonable and necessary services for the condition of the particular patient at the time of the encounter as documented can be considered when selecting the appropriate level of an E&M service. Information that has no pertinence to the patient's situation at that specific time cannot be counted.