Medicare Administrative Contractors (MACs) warn that individualized patient notes are required for each patient visit, and that use of “cloned notes” may cause a provider to overlook new information, resulting in treatment, safety, and quality issues.
A patient encounter note in an EHR is considered to be cloned when patient information is copied from notes taken at a previous appointment into a note intended to report findings and recommendations for the current appointment. Many EHRs allow providers to use default templates for various symptoms, but problems arise when copying old information into a new note. Previous patient complaints, old blood pressure readings or lab results, or similar types of event-specific data may be carried over into notes for the current visit without being noticed, and can distort, confuse, or contradict information that is added to the new record if the old information is not thoroughly reviewed and removed as appropriate. Submitting claims based on cloned documentation—especially if it results in billing for a code with higher specificity--is considered to be a misrepresentation of the medical necessity requirement for coverage of services, due to the lack of specific, timely and personal information for each unique visit.
Making use of the templates included in electronic medical record software can be both convenient and efficient, but it is crucial that each new record created includes the personalized detail CMS requires for payment. It’s ironic that the features that make EHRs a boon to the healthcare industry are the same features that present opportunities for introducing errors or inaccuracies into the records themselves. It’s also relatively easy for MACs to identify cloned notes, because they tend to repeat the same language from record to record and patient to patient.
The federal government has used both financial incentives and penalties to encourage adoption of EHRs within the healthcare field, but the same pull-down menus, templates and macros that help these programs standardize presentation of clinical information also cause the information presented to take on a homogeneous quality. The crackdown on cloning is part of an ongoing effort by the Department of Health and Human Services (HHS) to prevent Medicare overpayments by policing how providers document and bill for services. Attorney General Eric Holder and HHS Secretary Kathleen Sebelius wrote that "a patient's care information must be verified individually to ensure accuracy; it cannot be cut and pasted from a different record of the patient, which risks medical errors as well as overpayments." So in spite of the inevitable repetition of language in records that have been standardized by a computer program, there still exists the need for individual patient records to feature language and information that distinguish one visit from another.
Thus, it’s simple to prevent running into troubles with Medicare or the MACs: If you regularly copy and paste information from patient records to create records for new visits, you must first read and edit what’s on the screen, eliminating all incident-specific information and replacing it with new findings before you treat the patient and submit the claim. Use of an EHR may simplify the process of taking and maintaining notes, but it does not replace the provider’s responsibility to ensure the accuracy of those notes and to submit claims based on levels of care documented in notes for each individual visit. The responsibility for this will always fall upon the provider, even as program developers make changes to the software addressing the issues that raise these concerns.