Palmetto GBA has recently announced that cloning is discouraged. Is that possible? When they are referring to the cloning of a medical record
“When documentation is worded exactly like or similar to previous entries, the documentation is referred to as cloned documentation.
Whether the cloned documentation is handwritten, the result of pre-printed template, or use or Electronic Health Records, cloning of documentation will be considered 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.
It would not be expected that every patient had the same exact problem, symptoms, and required the exact same treatment. Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information for each unique patient.
Documentation exactly the same from patient to patient is considered cloned and often occurs when services have a specific set of limited or select criteria. Cloned documentation lacks the patient specific information necessary to support services rendered to each individual patient.”
This goes against many of the EMR sales reps’ advice or recommendation that “you can speed up your documentation just by copying your previous visit” – So caution to you as you document. As the national terror threat drops and the budget crisis gets worse, you can anticipate that enforcement will increase.