By: Kathy Young, CEO, CPC, CPMA, Healthcare Chart Audits

About ten years ago I audited medical records for a provider who found himself in trouble with Blue Cross.  He coded pretty much every encounter as a level 4 office visit.  I reviewed the claims that Blue Cross had audited and then presented my report to the provider's attorney.  What I found was not what I had expected.  Instead of finding documentation that just did not support the coding, I found that each encounter looked almost exactly the same: pretty much word for word.  This was my first experience with documentation in an electronic health record (EHR) where there was cloning from encounter to encounter. 

Palmetto GBA defined this process in 2012:
The word "cloning" refers to documentation that is worded exactly like previous entries. This may also be referred to as "cut and paste" or "carried forward." Cloned documentation may be handwritten, but generally occurs when using a preprinted template or an Electronic Health Record (EHR). While these methods of documenting are acceptable, it would not be expected the same patient had the same exact problem, symptoms, and required the exact same treatment or the same patient had the same problem/situation on every encounter.

Cloned documentation does not meet medical necessity requirements 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.

The cloning process is a relatively unique problem of the EHR.  Prior to the use of an EHR, a provider might have at times stated in the dictation for the typist to copy and paste the history from the previous visit.  I saw this in some of these types of records and addressed it. 

But if you look at the EHR process as it is currently used, copy-paste or cloning is somewhat inevitable.  First of all, you have pull downs.  Pull downs are those lists of items in the template that allows pre-selected choices for the provider.  These choices may have been in the template that the EHR company supplied to the provider, or the provider may have created several choices based on how the practice reviews a patient, or the type or mix of patients they normally see.  The provider may have these pull downs in the review of systems or in the exam. There may also be pull downs in the medical decision making, such as labs or physical therapy.  

The problem with pre-selected choices is that providers like short cuts.  Let's face it: they did not go to medical school to learn how to type on a computer.  They went to school to learn to be healthcare providers.  The documentation has now become a nuisance, so the providers try to use other means to get the documentation done.  This will allow them to see the patient, finish the documentation, and avoid the office hounding them to finish their work.  So, what's a provider to do?  He finds short-cuts that make his office happy.  And what we are seeing is the cloned look of the medical records.

Before the expansion to the electronic health record, a provider might write a short scenario while examining the patient, and then they might go to their office and dictate a medical record that someone else types for them.  The paper they wrote goes into the chart with the dictated note.  The provider would then fill out an encounter form or super bill, choose the code and the diagnosis, and finally send it to the biller.  Billing was completed and eventually the insurance paid.  If the provider did not use dictation, the medical note that he wrote was used as the record and it may or may not have been legible. 

When the provider had to hand-write the notes, they normally did not write anything that did not happen in the encounter.  They wrote down only what they did, what they heard, and what they examined.  They were not going to write down something extra as it was going to take the time they did not want to spend. So, the record represented what really happened.  If they did a review of systems, they wrote down only the system(s) they actually reviewed.  They did not write down what they did not do as that would just be additional writing.  But, with the EHR, all they have to do is pull over the review of systems (ROS) from the previous visit or from the history and physical by simply clicking a spot on the EHR.  Whether they actually reviewed the systems with the patient is unclear, but all systems are now reported in each visit the patient makes to the office.

I underline the word "reported" as the history that is cloned has become a "report of systems" and not a review of systems.  It is reported as a part of the documentation but the purpose of a "review" of systems is for the provider to look at the full medical history of the patient and ask questions to see if the past medical history of the patient might be the cause for the presenting illness of the patient. 

The purpose of the ROS being in the History portion of the medical record is for the provider to see if there is a link between where the patient was in their health history, and is that affecting their current health condition.  The ROS is not just another tool to get a 99204 as the desired level of service so that the payment is bigger than a 99203.  The providers have now missed the purpose of the history of the patient if this is all that they do. 

I have a friend who was very sick.  She went from provider to provider trying to find out what was wrong with her.  Each provider gave her a new medication and each medication caused a side effect.  The next provider treated the side effect and then tried to address the problems that my friend had.  Eventually, she had a physical breakdown and ended up in the hospital with all the appearance that she was going to die.  A resident of that hospital sat by her bedside and really examined her chart.  He looked at her history and all her tests and all her medications and he came to the conclusion that they needed to start at square one.  He took her off of all medication and then began to work from there.  The problem for my friend had been that the providers she had been seeing did not carefully review her history, her medications, and her ROS.  They just kept adding to the problem.  Interestingly, there was a ROS listed on her medical documentation.  But the question is, did the provider review the history or was it just reported?  Did the medical assistant just write it down without the provider reviewing it? 

I recently did an audit of an office that uses an EHR with a function that always brings the original history over into the day's work.  The provider then is to go over it with the patient and only keep what is real for the visit and delete what is not.  As an auditor, I freaked out (I was a drama major in college).  I just knew this function was a nightmare for the practice.  They had me sit with the providers and watch them fill out the documentation in order to comfort me that they were only keeping what was real for that day's visit with the patient.  I calmed down and listened.  Whereas, I still do not agree with the process, they did prove to me that they were not cloning.  But not every provider and practice will follow that course of action.  I know from experience that there are providers that, if given the opportunity, will take that process of the EHR copy over the history as though it actually was reviewed when indeed it was not.  Medicare agrees and they consider this practice a misrepresentation of services rendered. 

Cloning not only happens in the history but it also happens in the exam.  I just completed an audit for a provider who not only clones within the individual patient account, but also clones from patient to patient.  His exam is a hard coded template.  It looks exactly the same from patient to patient unless he deliberately makes changes. Because the issue for the provider was an accusation of cloning, I asked for at least 3 encounters of the same patient.  I saw the cloning of the patient's history, but after the 3rd patient, I realized that the exam read exactly the same for each patient.  If any changes had been made, they were minor.  So, I not only had to look for any differences in the same patient but also from patient to patient.  It became quite the puzzle to work out.  An insurance auditor may not have spotted the cloning if they were just reviewing one patient.  However, if the auditor were to review several patients at the same time, then the cloning would have been spotted.  This problem may have occurred for years but no one saw it.  Over and over in my report back to the provider, I had to state that this was a misrepresentation of services rendered.  I cloned that statement in my report because I actually did perform the review.

Providers of healthcare often do not realize that the medical record is not just for them and their patient.  That may have been the case 20 years ago, but it is now a record for someone else to read.  The medical record is now for the provider, the billing office, the insurance company, the auditor, the next provider, and whoever is going to view it next. 

Listen up! A provider stands a greater chance of losing his practice to an audit from an insurance company then he does in losing his practice by a malpractice suit.  He went to school to learn how to take care of patients, and not to get in trouble for malpractice.  Only education and audits can help the provider on proper documentation, and to help him survive the world in which we currently live.       

Kathy Young, CEO, CPC, CPMA
Healthcare Chart Audits
www.healthcarechartaudits.com