Is Your Documentation Cloned?

Concerns Continue Around Copy-Pasting/Cloned Documentation

Gina Hobert, Healthcare Consulting Senior Manager
June 2016

Electronic health records (EHRs) replace traditional paper medical records with computerized recordkeeping to document and store patient health information. Experts in health information technology caution that EHR technology can make it easier to commit fraud.

In 2014, CMS conducted a study and indicated copy-pasting as one of the ways EHRs may facilitate fraud. Copy-pasting, also known as cloning, enables 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.

According to National Government Services (NGS), documentation is considered cloned when it is worded exactly like or similar to previous entries. It can also occur when the documentation is exactly the same from patient to patient: All diabetic patients start to look alike (no individuality); or every patient visit looks alike (difficult to differentiate one visit from another).

Whether the documentation was the result of an Electronic Health Record, or the use of a pre-printed template, or handwritten 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.

Cloning may be the most worrisome aspect of an EHR. Practices are more proactive today in doing coding audits and looking for patterns in documentation to identify potential cloning, noting concerns for quality and liability. A review may be as simple as obtaining 5-10 charts per provider; at least 3-4 from the same patient, in sequence. If a provider is found to be doing too much copying and pasting, additional training may be necessary.

Disclaimer of Liability: This publication is intended to provide general information to our clients and friends. It does not constitute accounting, tax, or legal advice; nor is it intended to convey a thorough treatment of the subject matter.