By ROLF LOWE
Over the last thirty years the transition from handwritten and dictated patient notes to electronic health records (EHR) has created efficiencies for providers. While EHRs were introduced with the idea of better patient care and less administrative burdens, they have also created issues that didn’t exist when the norm was to create a contemporaneous handwritten note in a patient’s chart. One of these issues is the “cloning” of a procedure or a SOAP note in a patient’s chart. The Centers for Medicare and Medicaid Services in its EHR Provider Fact Sheet defines cloning as the practice of copying and pasting previously recorded information from a prior note into a new note. The practice may also be referred to as copy and paste, carrying forward or same as last time (SALT). CMS, as well as other payers, see this as a problem in health care institutions and settings that is not being addressed.
One of the ways CMS is addressing this issue is through its various audit programs. Uniform Program Integrity Contractors (UPICs), who perform audit work for Medicare and Medicaid programs, rely heavily on Section 1888 of the Social Security Act, Payment for Benefits, when auditing a provider’s chart to deny a payment for service. The relevant section of 1888, Section (e) reads as follows:
No payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.
The UPICs will often look at multiple dates of service for a respective beneficiary, and then multiple beneficiary charts from a provider to deny payment for services. The reasoning provided by the UPICs is that due to the extensively cloned documentation from progress note to progress note and cloning of the “procedure note” itself from beneficiary to beneficiary, it can’t be determined if the patient received the billed procedure or if the provider was documenting on the correct patient.
The cloning of records can also impact more than just a provider’s revenue stream. Cloning records is an area of concern for risk management, and an area of enforcement for the Department of Regulatory and Licensing Affairs (LARA) Bureau of Health Professionals (BHP). From a risk management perspective, the cloning of records may not accurately reflect the patient’s conditions, which could impact the treatment provided, resulting in adverse consequences. Cloning or copying records is also a basis for the BHP to initiate disciplinary action against a provider, as copying records is seen as a violation of the Public Health Code, and more specifically the provider’s general duty to exercise due care, and a departure from the minimal prevailing standard of practice for their respective profession.
With the above in mind, providers should make sure they are generating a new entry in the patient chart, even though many of the observations may fall into the SALT category, with the understanding that certain clinical and medical terminology will remain unchanged. Words like systolic, aspiration, distal, nausea, fifth metatarsal are obviously the most accurate to use, but writing a little different prose and making observation of the patient and including answers from a patient to a few basic will clearly show that the note was not cloned when it is looked at months, if not years, down the road by a payer, regulatory body or plaintiff’s attorney. With an eye on compliance, providers should regularly review their medical and billing records side by side for accuracy, and as the saying goes, a short(contemporaneous) note is better than a long memory when it comes to defending your care.
For additional information or assistance on this subject or other areas of compliance please contact Rolf Lowe of Wachler & Associates at (248) 544-0888 or [email protected].