The practice of cloned or copy and pasted documentation is a significant issue in the use of electronic health records (EHRs). A recent study in the Journal of the American Medical Association, found that of hundreds of progress notes examined by researchers, just 18% were newly entered by clinicians (Wang, 2017).

Medicare (CMS), defines cloned documentation as “multiple entries in a patient’s health record that are exactly alike or similar to other entries in the same patient’s health record or another patient’s health record” (CMS, n.d.) Terms used for duplicative documentation also includes cloning, copy and paste, copy forward, macros, and save notes as a template.

Let me explain:

• Cloned Documentation: Medical Record documentation that has been cut and pasted from another source location, which may or may not accurately reflect information specific to the current patient encounter.
• Copy and Paste: Selecting data from an original source or previous source to reproduce at another location.
• Cut and Paste: Removing or deleting the original source text or data to place in another location. Cut and paste should never be allowed, as it alters the original source material.
• Copy Forward: A function that copies a significant section of a prior note.
• Template: Documentation tools that feature predefined text and text options used to document the patient visit within a note.
• Populating by Default: Data that is entered into a note via an electronic feature that does not require positive action or selection by the author.

There are several issues with “cloned noting” that can be a red-flag for a potential audit in your clinics and offices as well.

First, Inappropriate use of cloned documentation can damage the trustworthiness and integrity of the record for patient care. There are also reimbursement implications of cloned documentation that lack patient-specific information necessary to support medical necessity requirements for services rendered to an individual patient.

The OIG (Office of Inspector General) issued the following statement in 2013, concerned with copy and paste practices:

Copy-pasting, also known as cloning, allows users to select information from one source and replicate it in another location. When doctors, nurses, or other clinicians copy-paste information, but fail to update it or ensure accuracy, inaccurate information may enter the patient’s medical record and inappropriate charges may be billed to patients and third-party health care payers. Furthermore, inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.

Over documentation is the practice of inserting false or irrelevant documentation to create the appearance of support for billing a higher-level of service. Some EMR/EHR. Technologies auto-populate fields when using templates built into their system. Other systems generate extensive documentation on the basis of a single click of a checkbox, which if not appropriately edited by the provider, may be inaccurate. Such features can produce information suggesting the practitioner performed more comprehensive services than were actually rendered.

Since the beginning of EHR/EMR implementation many reputable sources have weighed in on the risks associated with copy and paste practices. AHIMA, several MAC contractors, such as Noridian and FCS Options, and Palmetto have voiced their opinions loudly.

Noridian Healthcare Solutions, LLC (the biggest MAC payer in the U.S.), created a local coverage determination (LCD) guidance on using E.H.R. templates when documenting a patient encounter, specifying:

Documentation to support services rendered needs to be patient specific and date of service specific. These auto-populated paragraphs provide useful information such as the etiology, standards of practice, and general goals of a particular diagnosis. However, they are generalizations and do not support medical necessary information that correlates to the management of a particular patient. Part B medical records are seeing the same auto-populated paragraphs in the HPIs of different patients. Credit cannot be granted for information that is not patient specific and date of service specific.

The integrity of the health record should be protected at all costs. Our consultants at NSCHBC can assist you in how to incorporate policies and procedures to protect your records.

It is never too late to be proactive with continued implementation of EHRs that continue to come with the risk of misuse copy and paste functionality. We are here to provide guidance on this issue and make sure you are complaint in your practices, ensuring the integrity of documentation used for patient care. We invite you to search our consultant panel on the “Find A Consultant” tap of the NSCSBC website. We are here to help.

References

• CMS (n.d). Claims Processing Manual, Pub. No. 100-04. Ch 12, ⱡ 30.6.1
• OIG (December 2013) Not all fraud safeguards have been implemented in hospital EHR technology
• JAMA, (May, 2017 Wang).