Medical Record Cloning
Electronic Health Records (EHRs) allow medical professionals a seamless approach for coordinating and managing their patient records.
They can help reduce paperwork, eliminate duplicate tests and facilitate code assignment for billing. However, it should be noted that recent reports indicate physicians are concerned about system interoperability, documentation overload and untested billing systems.
While EHRs can improve health care delivery and provider services, they can pose provider challenges. Challenges include, but are not limited to, privacy and security, author identification, altering entry dates, cloning, upcoding and coding modifiers.
Cloning occurs when medical documentation is the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms and required the exact same treatment. This 'cloned documentation' does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information.
All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement 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.
Cloning involves copying and pasting previously recorded information from a prior note into a new note, and it is a problem in health care institutions that is not broadly addressed. For example, features like autofill and auto-prompts can facilitate and improve provider documentation, but they can also be misused. The medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter. Simply changing the date on the EHR without reflecting what occurred during the actual visit is not acceptable.
Using electronic signatures or a personal identification number may help deter some of the possible fraud, waste and abuse that can occur with increased use of EHRs. In its 2013 work plan, the U.S. Department of Health, and Human Services, Office of Inspector General (HHS-OIG) indicated that due to the growing problem of cloning, its staff would be paying close attention to EHR cloning.
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