Though Electronic Health Records (EHRs) can support appropriate documentation for billing higher level evaluation and management (E/M) services for Medicare, cloning of medical records or copying the content from previous visits with EHR can defy the purpose. In addition to the individual requirements of the CPT code for E/M services, medical necessity is also an important criterion for payment. Cloning of documentation is regarded as a misrepresentation of the medical necessity requirement for coverage of services. When such kind of documentation is identified, it will result in denial of payment for lack of medical necessity and recoupment of all overpayments made.
Evaluation and Management services are easily recognizable medical services (for example, a visit to urgent care, hospital admission, or daily rounds in a hospital) and they have multiple levels corresponding to different levels of complexity (for example, ‘new outpatient visit – level 4’). Medicare’s Claims Processing Manual states that it would not be medically necessary or appropriate to bill a higher level E/M service while a lower level of service is warranted. Documentation should support the level of service reported also since choosing the correct level is critical to being paid appropriately for the encounter. It is stated in the Medicare B Update, third quarter 2006 that a particular documentation is considered cloned when each entry in the medical record for a beneficiary sounds exactly like or similar to that of previous entries or if the medical documentation is exactly the same from beneficiary to beneficiary. Surely, it cannot be expected that every patient would have exactly the same problem, symptoms and require exactly the same treatment. Cloned documentation does not meet the requirements for coverage of E/M services due to this lack of specific and individual information.
In order to meet medical necessity requirements for coverage of E/M services, all documentation in the medical record must be specific to the patient and her/his condition at the time of the encounter. Each piece of information should be relevant to the encounter and to the patient, instead of recording the information on the basis of how the last visit went with a previous patient. To achieve this, physicians can adopt the following practices.
- Avoid Frequent Copy and Paste – Copy pasting of data within EHR can save time for physicians. At the same time, it is very important to ensure that each patient encounter is distinct and separately identifiable from other patient encounters within the electronic records. When physicians copy and paste data frequently, they may not have enough time to check the data and its impact, which may cause two patient encounters to look exactly similar. So, it is better to avoid regularly using the copy and paste functions.
- Use Customized Templates – In order to have a distinctive medical record, there should be unique templates to insert personal information. Instead of having a comprehensive history with a complete review of systems (ROS), and a comprehensive exam and using that template for all patients, set up individual templates that cover various E/M levels. For example, Medical Decision Making (MDM) is an important factor in determining the level of E/M service and it is better to set up one template for each level of MDM (low, moderate, and high complexity).
In short, physicians should remain vigilant of cloning by avoiding the use of copy and paste functions and adopting customized EHR. However, a practical solution is to obtain medical billing services from a provider with rich expertise in EHR to save time and keep abreast of changing billing guidelines.