Cloned EHR notes lead to denials, CMS contractor says

by Ben Penn on Sep 11, 2012

We’ve been ringing the alarm on cloned EHR (electronic health record) visit notes for the past year, but if you’re looking for more proof that these vendor shortcomings can lead to denied claims, then perhaps the warning below from a Medicare administrative contractor (MAC) will suffice:

“Cloned documentation will be considered misrepresentation of the medical necessity requirement for coverage of services due to the lack of specific individual information for each unique patient,” writes MAC National Government Services. “Identification of this type of documentation will lead to denial of services for lack of medical necessity and the recoupment of all overpayments made.”

Cloned notes – PBN 6/4/12, PBN 5/21/12, PBN 1/9/12– refer to documentation, usually on EHR, that repeats language from previous entries on that patient or from other patients with similar conditions. It lacks the individualized detail CMS requires for payment and is a product of certain EHR vendors’ failure to understand CMS policy.

Certainly don’t sweep all vendors under the rug as guilty of leading you into cloned note traps. Instead, work with your vendor on solutions and keep an open mind to using the technology to increase efficiency at your office.

The information contained herein was current as of the publication date. © Copyright DecisionHealth, all rights reserved. Electronic or print redistribution without prior written permission of DecisionHealth is strictly prohibited by federal copyright law.