Cloned EHR Notes Jeopardize Medicare Payment

September 25, 2012

September 25, 2012 — Companies that process Medicare claims are threatening to deny them if physicians document patient visits by cutting and pasting notes from previous visits in their electronic health record (EHR) systems.

This ability to carry forward old clinical information into the latest note — an explicit feature of some EHRs — is often referred to as cloning. The problem lies in copying forward old information, such as patient complaints from an earlier visit that have resolved themselves or old blood pressure readings.

Earlier this month, a Medicare Administrative Contractor (MAC) called National Government Services (NGS) in Indianapolis, Indiana, announced that it would recoup payment for Medicare claims if an audit uncovered cloned documentation.

"Cloned documentation will be considered misrepresentation of the medical necessity requirement for coverage of services due to the lack of specific individual information for each unique patient," NGS said in a Web site posting.

Michael Davis, a manager of provider outreach and education at NGS, told Medscape Medical News that cloned documentation has been on the company's radar since the advent of EHRs. However, it has increasingly become an issue as EHR technology goes mainstream. He chalks up this documentation misdeed not to fraudulent intent but to hectic physician schedules.

"It's very busy for providers," said Davis, whose MAC processes Medicare Part B claims for clinicians in New York and Connecticut. "It seems simple to cut and paste. It saves time. But the chart note does not demonstrate the unique care that each patient receives."

OIG Work Plan for 2012 Targets Copycat Charts

Other MACs that have put physicians on notice about cloned documentation include Palmetto Government Benefit Administrators (GBA) in Columbia, South Carolina; Cahaba GBA in Birmingham, Alabama; TrailBlazer Health Enterprises in Dallas, Texas; and First Coast Service Options in Jacksonville, Florida.

Several of the MACS state on their Web sites that cloning also describes medical documentation that is identical from patient to patient.

"It would not be expected that every patient has the same exact problem, symptoms, and required the same exact treatment," says First Coast Service Options.

The crackdown on cloning is part of an effort by the Department of Health and Human Services (HHS) to prevent Medicare overpayments by policing how physicians document and bill for evaluation and management (E/M) services. In its work plan for 2012, the HHS Office of Inspector General stated that it would review "multiple E/M services for the same providers and beneficiaries" to identify EHR practices linked to potentially improper payments. MACs had noted that more and more medical records had "identical documentation across services," the OIG said.

On September 24 the government turned up the heat even more when HHS Secretary Kathleen Sebelius and US Attorney General Eric Holder Jr warned the American Hospital Association, 3 other hospital industry groups, and the Association of American Medical Colleges in a letter that it would "pursue healthcare providers who misuse electronic health records to bill for services never provided."

"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," Holder and Sebelius wrote.

Copied Documentation Must Be Edited

To some physicians, denying claims on account of cloned documentation smacks of unfairness. They argue that Centers for Medicare and Medicaid Services guidelines for E/M services force physicians to document elements of the patient history, physical exam, and medical decision-making in excruciating detail — all but driving them to automate this process with EHRs.

At the same time, the federal government has used financial incentives and penalties to push physicians to adopt EHR technology. With its templates, pick lists, and macros, this technology standardizes clinical information, so it is little wonder that documentation looks cookie cutterish from patient to patient. And now physicians are being punished, the argument goes, for the natural consequences of following Uncle Sam's lead.

"Joseph Heller would be proud — Catch 22 is alive and well," William Lawson, MD, wrote last year in an article about "the Clone War" that was posted on a Web site called Holistic Primary Care. "More physicians are realizing that money from the government should be approached like a mouse approaches cheese on a trap. It's not food, it's bait."

Barb Drury, a healthcare information technology consultant in Larkspur, Colorado, sympathizes with physicians who feel caught in a high-tech mousetrap.

"I think [HHS] would have a challenge figuring out what 'clone' is defined as," Drury told Medscape Medical News. For example, some — but not all — EHRs relentlessly list data entries such as laboratory test orders in alphabetical order, even though they were not entered that way. That technological tic can give the impression of cloning, Drury said. The very nature of treating chronic illnesses comes with a sameness that can be confused with lazy cutting and pasting, she added.

"If I saw you for hypertension a month ago and I saw you for hypertension today, 99% of the symptoms will be exactly the same," Drury said.

At some point, however, EHR efficiency crosses the line into EHR abuse, as illustrated in an article on cloned documentation published in The Rheumatologist, a house organ of the American College of Rheumatology. In a follow-up visit for her arthritis, a 65-year-old woman reports that a new medication gives her diarrhea and stomach cramps. "Dr Brown" switches the woman to a new medication. During her next visit, in which the woman does not complain of diarrhea or stomach cramps, Dr. Brown pulls forward the note from the previous visit, but neglects to delete the references to diarrhea and stomach cramps. The woman's condition, therefore, looks worse than it actually is.

Because more active diagnoses for a visit can help justify a higher and more lucrative level of E/M services (more worthy of Current Procedural Terminology code 99214 than 99213, for example), this example of cloned documentation could result in a Medicare overpayment. It is more likely to happen if the EHR automatically suggests an E/M code based on the entered data.

The answer to this problem is simple, said Drury. Physicians who carry forward a previous note into a new visit must read and edit what is on the screen for the sake of accuracy.

"If you sign [the note] and say, 'That's what I saw, that's what I said, that's what I told the patient to do,' that's what you're swearing to," said Drury. "If you don't have the time to read it and you still want to pull [notes] forward, you're just asking for trouble."