When cutting-and-pasting EHR progress notes leads to denials, and worse
In 2009, technological advances led the United States government to advocate electronic health record (EHR) use.1 As a practitioner who started practice by handwriting all his notes, the increased availability of EHR software was an advantage in practice, and well worth the investment. However, as EHR companies became more prevalent, they touted their system as saving more time for the practitioner. Decreased time at the computer became the main objective of some EHR companies — and practitioners. Accuracy was sometimes discarded and replaced by efficiency. The efficiency of EHR systems developed drawbacks with the advent of copy-and-pasting EHR progressnotes, known as cloning.
Cloning is fraud
The path chosen is typically that of least resistance. Medicare and its contractors issued notices warning that cloned notes and notes that carry over information from one encounter to another are considered fraud.2 If a test or service was not done on that particular day, it should not be in the record.
As a compliance and risk management officer for individuals and a major health care company, I am often asked to review the provider’s notes for risk management assessment. In recent years, I have seen an alarming increase in the use of cloning of EHR progress notes. I realize our notes have the same format from patient to patient, and templates help guide the provider in crafting an adequate record that tells the patient’s story. However, as an example, when the provider documents that they did a visual posture inspection and evaluation for 20 consecutive encounters and never does an assessment of the feet and its effect on the kinetic chain, it becomes doubtful that the chiropractor actually did the service, and that the medical necessity of the service was ever considered.
An overriding criterion in providing care to a patient is that the care must be medically necessary, and the patient is expected to show improvement in their condition. When large sections of the note are cloned such as the subjective and objective portions of the note, one can hardly argue that the patient is “improving as expected” when the patient’s complaints and the doctor’s findings have remained constant for a given length of time.
In the 1980s, practice management companies suggested that lengthy notes would enhance reimbursement. They insisted that certain buzzwords, such as a car crash, would somehow sway the jurors to reward higher amounts of money than if the practitioner used the word accident in their report.
Lawyers, jurors and common-sense providers saw through that argument. The term “note bloat” came into existence because of the voluminous notes that resulted from advice such as this.
Electronic health record advantages became evident in the recent hurricanes in Florida. Offices still on paper systems saw the integrity of their patient records ruined in the aftermath of the storm from the ravages of the water and wind. Although a hardship, documentation kept safely in a cloud-based storage system ensured patient records were preserved and financial records of the office’s accounts receivable were intact.
In light of these facts, providers should take note of the increased risk of denials, recoupment and alleged negligence when cloning their patient notes. A trained eye can identify cloned records quickly. Features such as auto-fills and auto-prompts may aid the provider in improving their documentation. However, when misused, reviewers and litigants will point out the inaccuracies of documentation and the lack of progress by the patient because of the same findings over time. Inaccuracies in documentation will only impugn the doctor’s reputation and increase their risk for costly legal judgments.
Cash practices and cloning of EHR progress notes
Even cash practices are not immune. Cash-based practices often feel exempted from litigation and scrutiny because they do not file claims directly to an insurance carrier.
Upon further research, it becomes evident that all National Board of Chiropractic Examiners’ guidelines for each state have regulations governing proper documentation and record-keeping practices. Plus, do not forget that a chiropractor cannot see Medicare patients and opt out of the Medicare system.
It is strongly advised that providers start by self-auditing their notes for evidence of cloning, inaccuracies and false statements. Once satisfied, the provider should have their notes reviewed by a certified reviewer or compliance specialist for risky business practices. We can all agree that a trained compliance specialist who advocates for you offers peace of mind and a better experience than an insurance carrier or government agency investigator.
Records should be timely and identify the note’s author and credentials.3 The EHR system should be able to identify changes to an original entry due to errors. Changes to the record can be accomplished through addendums by the provider, corrections and patient amendments to the information provided. All EHR progress notes notes must be dated and signed. It is best to complete the note in 24-48 hours to ensure accuracy.
The chart notes should be understood by a chiropractic peer and create a story of the patient’s complaints, examination findings and response to the provider’s care. The assessment of the note is an analysis of the subjective and objective entries by the provider. The assessment portion of a SOAP note should contain the provider’s opinion on how the case is progressing, explain inconsistencies, and provide insight into situations that may impede the patient’s progress.
The plan portion of the note must support the services’ billing, indicating the service’s medical necessity and rationale, the actual segments manipulated, the technique used, and the patient’s response to the treatment. An example would be supplying the necessary details when billing for services such as incorporating custom foot stabilization into chiropractic care. The documentation must support the billing and accurately reflect the level of service since upcoding and downcoding of services are also considered fraud.
Provide an accurate history of care
The documentation serves as a history of the patient’s care, not just for reimbursement. If something should happen to the provider, another provider could step in and render further care to the patient.
Accurate documentation is the ethical responsibility laid upon each of us in the care of our patients. Accuracy of records will lead to better patient care, improved outcomes, referrals and an enhanced image of our profession.
MARIO FUCINARI, DC, CPCO, CPPM, CIC, is a Certified Professional Compliance Officer, Certified Physician Practice Manager, Certified Insurance Consultant and a Medicare Carrier Advisory Committee member. As a member of the Foot Levelers Speaker’s Bureau, he travels throughout the year speaking to audiences across the country, sharing his chiropractic expertise and insights about using custom three-arch orthotics for optimal care. For further information, email him at Doc@Askmario.com or check his website at Askmario.com.
- White House. Office of the Press Secretary. (2009, June 15). Remarks by President Obama at the Annual Conference of the American Medical Association. www.whitehouse.gov/the_press_office/Remarks-by-the-President-to-the-Annual-Conference-of-the-American-Medical-Association/
- Electronic Health Records Provider, page 2, https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/docmatters-ehr-providerfactsheet.pdf.
- Medicare Program Integrity Manual, Chapter 3 – Verifying Potential Errors and Taking Corrective Actions, 22.214.171.124 – Amendments, Corrections and Delayed Entries in Medical Documentation (Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20)