Cutting and pasting, also referred to as cloning, is not a new topic within the realm of the medical record but it has great implications and requires HIM to be the drivers of decisions and internal policies to safeguard against this problem.
The introduction and advancement of the electronic health record has exacerbated the issue of cutting and pasting. This is due partly to the functionality and design of the EHR, but is also because of the increasing demands on provider’s time and the push for increased billing.
Attention was elevated around this subject when the Office of the Inspector General added the review for duplicate documentation to their fiscal year 2012 Work Plan. Translated, that means denied Medicare payments.
What is the OIG looking for? They are auditing for health records with identical documentation. Medicare defines duplicate documentation as multiple entries in an individual’s health record that are worded exactly alike or similar to other entries.
In an August 2012 National General Services article entitled “Cloned Documentation Could Result in Medicare Denials for Payment” the NGS says “documentation is considered cloned when it is worded exactly like or similar to previous entries. It can also occur when the documentation is exactly the same from patient to patient. 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.
Whether the documentation was the result of an electronic health record, or the use of a pre-printed template, or handwritten documentation, cloned documentation will be considered misrepresentation of the medical necessity requirement for coverage of services due to the lack of specific individual information for each unique patient. Identification of this type of documentation will lead to denial of services for lack of medical necessity and the recoupment of all overpayments made.”
A great deal of work has and will be done to eliminate cutting, pasting and cloning. It’s too bad that it takes the heavy arm of OIG and payment denials to elevate the issue because the real issue here is the accurate continuum of the patient’s narrative.
Healthcare leadership, hospitals and providers are squeezed financially, forcing them to stretch to attest for reimbursement. In the middle of all of this is the HIM professional responsible for developing and implementing policies and practices.
You may have a strong copy functionality policy in place, the means to monitor, and the support from administration to enforce the rules; however, if you are looking for a resource to bolster your policy then take a look at AHIMA’s Copy Functionality Toolkit,Copy Functionality Toolkit, Copy Functionality Toolkit, A Practical Guide: Information Management and Governance of Copy Functions in Electronic Health Record Systems.
If you have a few minutes I’d love to hear your thoughts on copying and pasting. Are we headed back to thinking about what other types of technology would be best suited to improve provider efficiency, accuracy and compliance? And do you think the use of dictation to a greater extent within the templates is a good solution? Post your comments below or email me at firstname.lastname@example.org.
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