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Medicare Watchdogs, Compliance Officers Investigate ‘Carry Forward’ (with Two MACs’ Policies on Cloning Electronic Medical Records)

Reprinted from REPORT ON MEDICARE COMPLIANCE, the nation's leading source of news and strategic information on Medicare compliance, Stark and other big-dollar issues of concern to health care compliance officers.

By Nina Youngstrom, Managing Editor
August 15, 2011Volume 20Issue 29

Medicare has no national policy on electronic medical records shortcuts, such as templates and copy/paste,¸ yet all signs point to greater scrutiny in this area.

The HHS Office of Inspector General’s 2011 Work Plan targets electronic medical record documentation practices “associated with potentially improper payments,” and Medicare administrative contractors (MACs) have noted greater use of “identical documentation,” a euphemism for cloning. But that won’t stop this freight train, because electronic templates and copy/paste potentially make a lot of things better, such as legibility, billing accuracy and communication.

Instead, some hospitals — and in particular, compliance officers — are stepping up oversight of templates and copy/paste. But they have a formidable challenge ahead of them. When Medicare contractors don’t agree on the definition of a “cloned note,” how can compliance officers assess whether cloning has, in fact, occurred and whether quality has been affected? “We are left holding the bag,” said Julie Appleton, manager of compliance and corporate integrity at Vanderbilt Medical Center in Nashville.

There’s no question that templates and copy/paste — which Vanderbilt calls “carry forward” — have great benefits. But they have a potential dark side, in terms of quality of care and billing compliance. Hospitals should explore whether carry forward increases the risk of clinical documentation errors, poor patient outcomes, unnecessary documentation, greater payer scrutiny for denials of services rendered, inadvertent slowing of the delivery of care due to “documentation overkill,” and cloning, which means copying a note from one patient encounter to the next with little or no editing.

To identify the risks and rewards of carry forward and decide whether and how to rein it in, Vanderbilt formed a committee that included compliance, legal, health information management, physicians and others. The committee looked into the literature about carry forward and templates, researched whether and how other institutions used them and identified MAC policies in this area, said Appleton, who spoke at a recent Health Care Compliance Assn. conference. “What we found was some facilities use copy paste and some don’t,” Appleton said. “Most institutions that allow it have little or no governance. They either turn it on or turn it off.” And it turns out that MACs have varying definitions, she said (see box below).

For example, First Coast Options has a “great definition” for people engaged in blatantly illegal conduct, such as pill mills, said Chris Thomason, Vanderbilt’s director of compliance and corporate integrity. It’s not practical for mainstream providers trying to find compliant ways to use these tools. But Cahaba’s definition “was very helpful for us,” said Thomason, who also spoke at the conference.

Pros and Cons of Templates, Carry Forward

There are benefits and risks with templates and carry forward in electronic medical records, the Vanderbilt committee discovered. Among them:

• Templates in electronic medical records ease physician communication and promote documentation speed/ efficiency and billing accuracy. Physicians use templates to import vitals, review of systems and past family and social history, so they don’t have to repeat the documentation. “Macros,” which are symbols that stand in for a significant amount of information, also are a benefit of templates. When specialists treat the same conditions day after day, they use multiple macros that convey a lot of data with a few keystrokes, Thomason said. “They develop macros for positive, negative or unknown findings,” he said, although they usually require editing to reflect a particular patient.

The risks of templates, he said, include selecting the wrong macros for a situation or the wrong system or service performed. They may make editing mistakes and insert contradictions (e.g., the physician states the patient is negative and positive for the same disease or reports a female-type procedure on a male).

Templates also create documentation redundancy, Thomason noted. Payers eschew redundancy in the medical records because it creates more work during reviews “but from a clinical standpoint it could be beneficial,” he said. Research shows redundancy in documentation can demonstrate that a patient’s condition is not healing and can help physicians treat the patient. “The jury is out on whether redundancy is good or bad,” Thomason noted.

• Carry forward allows physicians to press a button and automatically drop a previous patient note into a new encounter. Like templates, carry forward is a time-saver, especially for inpatients whose conditions don’t change much from one day to the next. “But there are risks without controls,” Appleton said. Unless you monitor the use of carry forward, “there will be physicians who don’t edit their documentation properly.” For example, physicians may carry forward errors from visit to visit.

Ultimately, the committee came up with a policy governing the use of carry forward at Vanderbilt Medical Center. A summary of the policy defines carry forward as “the process of using previously documented text from notes, reports, or other electronic sources to document a current patient encounter. This encompasses a variety of processes including, but not limited to, copy/paste; reuse; and autopopulation functions, excluding dynamic data elements.”

Underlying this policy are these key principles, Appleton and Thomason said:

(1) Don’t document what you don’t do.

(2) If you sign documentation, you own it. “It’s easy for physicians to forget that if they sign an electronic medical record, their names are appended to it and bills go out under their names,” Thomason said.

Vanderbilt next built an auditing tool for carry forward. Its in-house IT department devised DISCO — the “discovery tool for compliance” — to monitor physician use of carry forward. “We do monthly audits” that are distinct from billing audits, Appleton said. The compliance office reviews 144 notes every month that have been carried forward. The tool identifies what percentage of the note was changed by the physician (e.g., 80% of the new note is identical and 20% was updated). After a certain threshold, a note is at high risk of cloning. Vanderbilt doesn’t tell its physicians how much editing is required to escape cloning because physicians may just change enough characters to cross the cloning threshold without substantively updating documentation. “When we think from an audit that a note is cloned, we let physicians decide whether it was clinically meaningful,” Appleton said.

When physicians use carry forward without significantly changing the documentation, an attestation statement will automatically pop up. Before physicians can save the medical record, they must check off a statement agreeing that the notes are accurate even if they’re pretty much the same as the previous encounter, Thomason says. “We were concerned if we added the attestation to every note, it might be a bull’s eye, so we thought it best to ask the question when very little of the note is changed,” he said. But physicians don’t know the percentage that triggers the attestation.

Vanderbilt built DISCO because no cloning audit tool exists, Appleton said. Yet there’s a need for tools and definitions as electronic medical records become the norm. There’s an upside to OIG’s scrutiny of identical documentation: “We are excited about potentially having a definition we can work with,” Appleton said. But what if OIG embraces a definition of “carry forward” that’s unfeasible for mainstream hospitals? Her apprehension is based on an OIG official referring to the First Coast Option definition of “cloning” during an HCCA webinar on the 2011 Work Plan. It seems aimed at providers and suppliers engaged in outright fraud, not hospitals and others trying to do the right thing.

Two MACs’ Policies on Cloning Electronic Medical Records

First Coast Services Options, Inc.

Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered a 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.

Cahaba Government Benefit Administrators LLC

The medical necessity of services performed must be documented in the medical record and Cahaba would expect to see documentation that supports the medical necessity of the service and any changes and or differences in the documentation of the history of present illness, review of system and physical examination.


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