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September 6, 2012

Electronic Medical Record Tips

When Using Electronic Medical Records

Electronic Health Records allow providers to copy forward clinical documentation. This process of copying existing text in the record and pasting it in a new destination is often used by clinicians to save time when updating notes on an existing patient, it is also known as copy and paste, cloning, and carry forward, among other terms.

Cloning occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. This "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 encounter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage 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.

REMEMBER

For Medicare, the medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.

Providers using electronic records should conduct regular self-audits to be sure your documentation meets the above mentioned criteria.


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