Templates, Ethics, and Chart Audits GOVERNMENT AGENCIES OBJECT TO CLONED DOCUMENTATION By Jennifer Searfoss, JD, CMPE, and Scott Kraft, CPC, CPMA has been difficult for clinicians to identify shortcuts that expedite their use of the electronic medical record (EMR) in ways that don’t bog down their day or leave too much charting for after-hours work. So, it makes sense that physicians and other medical professionals would find cloning of parts of the clinical note to be a good use of their time. But, as we’ll explain, the federal government does not condone such documentation. an august 2012 article posted by National government services (Ngs), one of the medicare administrative Contractors (maCs), defined cloned documentation as occurring when charts are “worded exactly like or similar to previous entries. It can also occur when the documentation is exactly the same from patient to patient.”1 since 2012, the issue of cloned notes has been identified by the federal government as a way for the medical community to cheat on rules and regulations. This is so prevalent that former Health and Human services secretary Kathleen sebelius and attorney general eric Holder issued a letter to several national medical associations after a New York Times front-page exposé on upcoding due to emr adoption.2 This started over concerns about hospitals and other organizations using unethical practices to meet meaningful use requirements and to upcode services by documenting sicker patients and higher levels of service. For the third year, the 2014 Health and Human services Office of Inspector general (OIg) work plan identified cloned notes as a keystone of its investigative work on medicare claims. The agency stated in this work plan that “medicare contractors have noted an increased frequency of medical records with identical documentation across services.” This context explains why evaluation and management (e&m) services remain as one of the top physician services still under review by the OIg. Cloning in the Field searfoss Consulting group (sCg) recently saw an example of cloning. The chart included a nice introductory statement about “a pleasant, 78-year-old female presenting in the office for management of COPD and congestive heart failure.” These types of statements are a big problem when the exact statement appears on six different charts, even when the patient has since had a birthday and is no longer 78 years old. Other examples in which similar text is generated include template text inserted with macros or the electronic medical record (emr) template itself. sCg staff came across one practice that even included in its transcription services common template macros to expedite the return of the record. like the example above, this It 8 HBma BIllINg • NOVemBer.DeCemBer.2014
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