FEATURE sTOrY The OIG views the use of cloning in any context or use of precise template language for documentation as inappropriate. THe jOurNal OF THe HealTHCare BIllINg aND maNagemeNT assOCIaTION 9 is inappropriate documentation in the eyes of the OIg. The OIg views the use of cloning in any context or use of precise template language for documentation as inappropriate and says it constitutes a “documentation vulnerability.” Future OIg guidance may provide specific direction on what is permitted. until then, providers should adhere to best practice guidelines. Private insurance companies are carefully watching the OIg and are following their steps in audits of their own networks’ medical records. Notably, private insurance companies are looking at a broader swath of claims and not just e&m services. For medicare, the National government services (Ngs) has said that “individualized patient notes for each patient encounter are required. Documentation must reflect the patient condition necessitating treatment, the treatment rendered, and, if applicable, the overall progress of the patient to demonstrate medical necessity.” The medicare contractor also indicates that prepopulated “default” language from the template may be considered cloned if it is not personalized to the patient and the specific encounter. 3 Further, the OIg has indicated only that it believes cloned records are “inappropriate.” Because it is not yet considered “waste, fraud, or abuse,” the claims based on cloned medical documentation will be recouped for those audited services or services reasonably extrapolated from a statistical sample of medicare claims. The retroactive denial will be for lack of documentation to support medical necessity. Indeed, Ngs’s website states that “identification of this type of documentation will lead to denial of services for lack of medical necessity and the recoupment of all overpayments made.”4 Keep in mind that the federal government can and likely will indicate that cloned records are an abusive practice and may in the future apply damages to the recoupment. Undermining Efficiency? The old adage of “garbage in, garbage out” is very true in the instance of cloned medical records. Outdated information reflecting the stage of disease prior to a change in diet, exercise, or a prescription drug regimen is helpful for context but not appropriate in every encounter’s record – unless it truly references the efficacy of the intervention. This very fact is why payors say cloned notes do not document medical necessity sufficiently to support coverage. many clinicians reviewing past medical records of colleagues or referral documentation find the charts cluttered with unnecessary information created by cloning of documentation. There is a fine line between being thorough and being obtuse. Best Practices Today let’s return to our pleasant 78-year-old female patient, whose charts were truly cloned. How could sCg staff tell? The notes for each of the encounters over a two-year period were nearly the same, even when prescriptions and other ancillary services were ordered for a “worsening condition.” You can bet that if we saw problems, federal contractors and private insurance auditors would as well. The following are best practices in regards to cloned documentation, along with recommendations for implementing them. BEST PRACTICE: REVIEW TEMPLATES The use of the medical record template by your clients is not considered a clone. Instead, it is an infrastructure for the capture of notes and can be specific to the patient and the encounter. However, from a legal standpoint, the template is discoverable in medical malpractice cases. Imagine if the template note, however arranged, does not include a question about some aspect of a medical condition. Plaintiff attorneys for the injured person can use the absence of a line of medical inquiry as proof of negligence. RECOMMENDATION: Have your clients review templates periodically as part of the medical audit to ensure compliance with current evidence-based medical protocols. BEST PRACTICE: AUDITS While the federal compliance plans and contracts with third-party
Billing_NovDec14
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