Cloned documentation on OIG radar screen in 2014

May 23rd, 2014 - Scott Kraft   
Categories:   Documentation Guidelines   Evaluation & Management (E/M)   Office of Inspector General (OIG)  

One of the areas where the OIG has its sights set in 2014 is on physician documentation. The OIG plans to review documentation of E/M services looking for what it describes as “documentation vulnerabilities.”

   Put more specifically, the OIG reports that Medicare Administrative Contractors (MACs) have seen an increase in instances of “identical documentation across services,” noting that code selection for E/M encounters is based on the documentation for the services rendered.
   
   If it sounds like they’re looking for cloned notes, it’s because they are looking for cloned notes. And with documentation generated by electronic health records (EHR) systems on the rise, and providers using EHR system tools that enable documentation to be carried forward to a new note, it’s likely that the OIG won’t have to look to far to see more cloning than they are comfortable with seeing.
  
   There’s no doubt that the bells and whistles of EHR systems have changed the way that physicians document E/M encounters.
  
   EHR systems make it easier to provide more robust documentation for each encounter and make it easier to port forward relevant documentation from previous encounters for the provider to review.
  
   After all, there are only so many different ways to report on the fact that a patient is being seen for the same chronic condition when the patient returns to your office on a regular schedule. There are also only so many ways to describe the elements of a review of systems or an examination.
  
   There are two problems, however, that the functionality of EHR is creating from a claims audit perspective. First, in too many instances the documentation for a single patient looks the same from encounter to encounter – across multiple encounters – because of the way in which the provider brings forward documentation.
  
   Second, the provider is choosing to consistently review the exact same systems in the same way for the review of systems and examination across multiple encounters, regardless of the patient’s presenting problem.
  
   Let’s look at the second problem first. Coders, billers and auditors are right to tread very carefully when it comes to second guessing the clinical judgment of the provider when it comes to deciding which systems are medically necessary to review and which exam elements are pertinent to the patient’s visit that day.
  
   There could be a very good reason for what appears to a third-party review to be a review of a system seemingly unrelated to the patient’s presenting problem.
  
   However, when a provider consistently reviews the same components of the same systems in the ROS across the patient population, without regard to the patient’s condition, it will appear suspicious to an auditor. It will look especially suspicious when the result is usage of high-level E/M codes that go beyond the typical practice pattern.
  
   Practically speaking, it stands to reason that the ROS and exam elements would not always be the same across the patient population because patients will show up with different chief complaints at different levels of severity.
  
    The same patient with multiple cloned notes raises a whole new set of problems, especially when documentation is being carried forward from note to note for a long period of time.

    One problem is that it becomes harder to determine what the provider addressed during that visit because the note contains a laundry list of the patient’s chronic and acute conditions. The structural integrity of the note, which is intended to represent what happened during that specific visit, becomes compromised.

    The problem is exacerbated when the same documentation appears in note after note. Sloppy mistakes begin to occur, including things like the patient’s age contradicting itself in the note because the HPI has been carried forward.

    Providers note that patients are often seen for the same conditions over a period of time and, to our earlier point, there are only so many ways to describe that a patient has asthma or COPD or some other condition. When you do bring condition detail forward from the HPI, address that by having the provider add to the HPI details about how the patient is doing on that day. After all, it is the history of the present illness.

    On contradictions, it is one of the biggest ways that cloned elements of notes are revealed. Because the information from previous notes is often brought forward by ancillary staff before the encounter, the provider will sometimes add contradictory information. An ROS that is negative for a headache is contradicted by an HPI of severe headaches.

    In an era where demands for the provider’s time continue to go up, without payment following closely behind, it is hard to walk away from the time-saving advantages that EHR systems can potentially provide. Just do it very carefully, and know that the auditors are going to be looking closely to make sure there is variety in your notes that reflect the documentation needs of a specific encounter.
 

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? 
Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....
Can We Score Interpretation of an EKG Towards E/M Medical Decision Making?
October 10th, 2023 - Aimee Wilcox
When EKGs are performed in the facility setting or even in the physician's office, what are the requirements for reporting the service and who gets credit for scoring data points for Evaluation and Management (E/M) medical decision making (MDM)? Let's take a look at a few coding scenarios related to EKG services to get a better understanding of why this can be problematic.



Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association