According to CMS, plan to prepare your office for additional scrutiny as the Office of Inspector General (OIG) pushes CMS contractors to look more carefully at suspected cloned notes and overdocumentation caused by electronic health record (EHR) workarounds.

In a January report, OIG looked at how contractors were adjusting their techniques to deal with computer-generated  documentation for Medicare claims and found they were not doing so at all, very much.  OIG reported, “…Few contractors were reviewing EHRs differently from paper medical records.”

Experts agree that this report–along with a hospital focused EHR report OIG issued in December–indicates CMS soon will order contractors to scour records for cloned notes, which could lead to denials and even fraud charges (PBN 10/29/12).

The report specifically mentions “copy-pasting” and “overdocumentation”–the signal features of cloned notes.  According to Medicare Part B News, “…that for all the talk of fraud, CMS is mainly interested in lazy shortcuts that, intentionally or not, misrepresent what the physician did.”

Many physicians have reported that it is critical to copy from a previous note in order not to “lose” the information and have it available easily at the next visit.  If they do not, it takes many pages to review the information if they don’t.  But this copy and pasting can cause documentation chaos if the note is not carefully edited, and most providers just aren’t always that careful.

A documentation that contradicts itself, besides screaming, “I’m a template and no one reviewed me,” can cause denials, affect continuity and quality of care, and can impeach credibility in the case of a lawsuit.

CMS offers the following tips to prepare for cloned-notes oversight:

–Don’t copy entire sections: while saving time, it will require a lot of editing that may be tempting to skip.

–Don’t copy-paste things that can change:  for example, HPI, exam, assessment and plan.

–Use free text features:  if progress notes do not change much, a quick free-text on the patient’s condition, spirits, etc, may dispel the suspicion that it is simply copied notes and the work wasn’t done.  The free-text notes also go to medical decision making, which will justify the level of service you’re claiming.

For more information, see www.partbnews.com and the OIG report “CMS and its Contractors Have Adopted Few Program Integrity Practices to Address Vulnerabilities in EHRs” http://oig.hhs.gov/oei/reports/oei-01-11-00571.asp