By: Justin Pierce
For efficiency's sake, there are times when physicians using electronic health record (EHR) systems may copy and paste the same progress notes from one chart to the next, especially if patients frequently present with the same complaints and conditions.
This process, often referred to as "cloning," may be common1, but it has come under increased scrutiny by the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services. In January 2014, the OIG reported that the activity may "mask true authorship of the medical record and distort information in the record to inflate health care claims."2 In other words, cloning is a red flag for fraud, according to the OIG, and contractors for the Centers for Medicare and Medicaid Services (CMS) need to step up their detection efforts.
Medical billing companies can help their clients prevent a CMS audit by educating them about the risky activity and advising them about systems that can help physicians create unique progress notes just as efficiently as copying and pasting. Practices will appreciate this risk management guidance that also helps them improve care quality by capturing more specific, unique patient information. The result of this advisory outreach will likely be a more satisfied client and a longer lasting business relationship.
EHRs facilitating cloned notes
In the days of paper medical records, cloning progress notes was not a significant concern because physicians documented with either handwriting or dictation. While physicians may have created similar notes in these instances, small differences in handwriting, wording, and details usually indicated that the documentation was unique.
With EHR systems, which 58 percent of physicians criticize for negatively impacting productivity3, copying and pasting notes is a simple shortcut to reduce the time spent charting, according to a February 2013 study in Critical Care Medicine. That study found that the progress notes from 82 percent of residents and 74 percent of attending physicians in an urban, academic medical center contained greater than or equal to 20 percent copied information.
The research did not determine if the physicians were motivated to clone notes due to productivity pressures, but did suggest that their EHR system's "copy forward" feature, where progress notes from the previous chart can be pasted to the next, "may provide physicians with an easy means to reduce workload."
Regulators take notice
Although the Critical Care Medicine study only focused on 73 physicians and 2,086 progress notes, its findings likely reflect a national copying-and-pasting trend that prompted the OIG to research the issue and publish its report earlier this year. The OIG found that claims fraud could be perpetuated using cloning because CMS contractors were "unlikely to identify copied language in a single claim because it may require a single reviewer to examine multiple claims from a single patient or provider for evidence of copied language," according to its report. Over-documentation, which the OIG defined as "inserting false or irrelevant documentation to create the appearance of support for billing higher level services," was easier for the contractors to identify in a single claim.
The OIG also found that CMS provided limited guidance to its contractors, including the RAC and ZPIC firms specifically charged with detecting fraud, to assist them in recognizing cloned progress notes. To remedy this issue, the OIG recommended that CMS offer its contractors more educational tools to detect cloning activity. Investigating EHR system audit logs, which capture data elements such as date, time, and user stamps for each patient record update, was also encouraged to identify data inconsistencies.
CMS, which responded to the OIG recommendations in the report, wrote that it plans to develop additional guidelines to ensure that providers appropriately use their EHR system's copy and paste feature and that it is also considering new instructional resources to help its contractors spot the fraud associated with cloning and over-documentation.
Making unique documentation efficient
Concurrently, billing companies should inform clients that CMS contractors, and likely commercial payers following the agency's lead, will be increasing their scrutiny of progress notes. Companies can help protect clients by identifying documentation that may draw regulatory attention and point out how modifying a few details would help ensure a unique note.
In addition, companies can educate their clients on how copying and pasting not only increases auditing risk, but it also means that crucial clinical details may be omitted from a patient's assessment or treatment plan, which could negatively impact outcomes in the future.
Clients may be interested to learn about EHR systems available that allow them to create progress notes using any method they choose, whether that is by typing, dictation or even handwriting, while still capturing all the information electronically. These systems also allow physicians to use their practice's existing forms so their established workflows and productivity will not be impacted.
Afterwards, when physicians discover that the new recommended EHR system helps them create unique progress notes faster and easier, the billing company will be viewed as more than just a service provider, but rather as a trusted advisor and partner that is committed to the well-being of the practice and its patients.
Justin Pierce is director of national sales and marketing for simplifyMD. www.simplifymd.com
1. "The Prevalence of Copied Information by Attendings and Residents in Critical Care Progress Notes," Critical Care Medicine, February 2013. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3718042/
2. "CMS and its contractors have adopted few program integrity practices to address vulnerabilities in EHRs," U.S. Department of Health and Human Services, Office of Inspector General, January 2014. http://oig.hhs.gov/oei/reports/oei-01-11-00571.pdf
3. "New IDC Health Insights Survey of Ambulatory Providers Reveals Dissatisfaction with Ambulatory EHR," November 13, 2013. http://www.idc.com/getdoc.jsp?containerId=prUS24443913
