Why ‘SALTing,’ aka cloning notes, is a bad idea

‘Same as last time’ documentation and the trouble that follows

YOU’RE IN THE MIDDLE OF A BUSY DAY. Your front desk has a patient scheduled every 10 minutes for the next two hours. Thank the programmers of your electronic health records that they installed a “Same as Last Time” (SALT) feature that brings forward the patient’s notes from the last visit. You’ll just bring forward the last record and edit it later.   

This is most commonly referred to as “cloning” medical records, and here’s why it is a bad idea.   

Cut-and-paste technology

To start this conversation, let’s think back to a time before computers kept our records for us. Would you have copied the patient’s previous visit records, added a line or two of new tests, and called it good for that visit? No, you wouldn’t, and that’s good because at that time it would have been considered fraud or, at the very least, abuse.   

The same thing applies to the world of electronic health records. Cloning notes from the previous date of service opens the doctor up to malpractice, regulatory problems and claim denial problems. The Centers for Medicare and Medicaid Services (CMS), the Office of Inspector General for Health and Human Services (OIG) and the Special Investigative Units for insurance companies are all aware of documentation cloning and are actively looking for it. 

I have personally seen documentation of a patient with extremely high blood pressure where the chiropractor advised it would be checked on the next visit, and if it was still high, would refer the patient to their primary care provider. Not a particularly unusual entry except that the doctor had cloned this particular note several times. Now in this case the patient suffered no ill effects; however, had the patient suffered a stroke, the chiropractor would have been in an absolutely impossible position relating to malpractice. 

The CMS and cloning

In June of 2016, CMS published a Decision Table for Ensuring Proper Use of Electronic Health Records Features and Capabilities. The first item that they address is the cloning of notes.   

Here is what they consider to be the issue with this practice: “Copy-and-paste or cloning can lead to redundant and inaccurate information in EHRs. Using this feature can cause authorship integrity issues since documentation cannot be tracked to the original source. Cloned documentation lacks the patient-specific information necessary to support services rendered to each patient. This can affect the quality of care and can cause improper payments due to: 

• False impression of services provided to the patient 
• Coding from old or outdated information that may lead to “upcoding”” 

Clearly CMS is not a fan of cloned notes. Now just in case you think that I am making a much bigger deal out of cloning notes than is justified, let me show you an OIG case from January of 2016: 

“After it self-disclosed conduct to OIG, Somerset Cardiology Group, P.C. (Somerset), New Jersey, agreed to pay $422,741.50 for allegedly violating the Civil Monetary Penalties Law. OIG alleged that Somerset knowingly presented claims to Medicare for items or services that it knew or should have known were not provided as claims and were false and fraudulent. Specifically, OIG contended that Somerset cloned patient progress notes, as well as improperly coded and submitted for payment to Medicare E&M services that used current procedural terminology codes to reflect a higher level of service than the cardiologists actually preformed, resulting in higher payments by Medicare to which Somerset was not entitled.”   

It is important to note that this is a self-disclosure case where the OIG is far more lenient than they would be if they had to do the work to discover the problem on their own. If the OIG has to find the problem by investigating, they start by fining you several thousand dollars per occurrence and exclude you from participation in federal health care programs for at least three years. 

Medicare and cloning

The Medicare Administrative Contractors are looking for cloned notes too.   

Palmetto GBA on their website for Jurisdiction M states on their Medical Record Cloning page:  

“Cloned documentation does not meet medical necessity requirements 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.”   

I think that makes their position pretty clear. 

EHR programmers put the cloning feature into their products, by whatever name they choose to use, because doctors want that feature. And doctors want that feature because they think that it will make their lives easier and save them time in their practice. In the short term this may be true, but you can see that in the long term this can open you up to considerable risk to yourself and your practice. 

The documentation for each date of service needs to reflect what happened on that date of service. Because of the nature of the chiropractic treatment paradigm, our treatment visit documentation tends to look very similar from one visit to the next. Therefore, we need to take care to note the differences from one visit to the next. The difference may be as simple as a different score on the Numeric Pain Scale or a patient comment regarding how they feel on that day. Whatever that difference is, be sure and document it. That way you will have a defense should you ever be accused of cloning your notes. 

A notes policy

Another good defense from an accusation of note cloning is having a policy in your Office Compliance Program that states that notes will not be cloned from one date of service to the next.   

Having an effective Office Compliance Program (and to be clear, an effective Office Compliance Program is one that is actively followed and used within your office) is your best defense from any accusation of impropriety. 

Document accurately and properly and refrain from using short cuts regardless of how tempting they may be, and you will be much better off in the long run. Everyone is looking for cloned notes and nobody will praise you for doing it. 

RON SHORT, DC, MCS-P, CPC, CPCO, is a 1985 graduate of Palmer College of Chiropractic and is a certified Medical Compliance Specialist, a Certified Professional Coder, a Certified Professional Compliance Officer, a Certified Insurance Consultant and a Certified Peer Review Specialist. He presents seminars and webinars across the country on Medicare, compliance, coding and billing, and documentation. He has written five books and several articles on Medicare, and is available to speak at group or association meetings or to assist with reviews, audits, appeals or the development of a compliance program. He can be contacted at chiromedicare@gmail.com or at 217-653-5921.