Awareness : OBC Tips

Electronic Health Records (EHR) Cloning of Documentation

Electronic Health Records (EHR) Cloning of Documentation

Documentation is considered cloned when each entry in the medical record a is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from patient to patient. 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 en-counter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement for cover-age 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.

Cut & Paste

ACCORDING TO THE OIG

“Electronic health records (EHR) may not only facilitate more accurate billing and increased quality of care, but also fraudulent billing. The very aspects of EHRs that make a physician’s job easier—cut and paste features and templates can also be used to fabricate information that results in improper payments and leaves in-accurate, and therefore potentially dangerous, information in the patient record. And because the evidence of such improper behavior may be in entirely electronic form, law enforcement will have to develop new investigation tech-niques to supplement the traditional meth-ods used to examine the authenticity and accuracy of paper records.“