Additionally, Noridian Administrative Services LLC created Local Coverage Determination (LCD) guidance on using EHR templates when documenting a patient encounter:
Documentation to support services rendered needs to be patient specific and date of service specific. These auto-populated paragraphs provide useful information such as the etiology, standards of practice, and general goals of a particular diagnosis. However, they are generalizations and do not support medically necessary information that correlates to the management of the particular patient. Part B medical record is seeing the same auto‐populated paragraphs in the HPIs of different patients. Credit cannot be granted for information that is not patient specific and date of service specific.4
Implementing and monitoring utilization standards for EHRs are important and should be executed in practices’ policies and procedures. Below is a sample policy template that can be customized to meet the needs of the individual practice. Guidelines that may be added to an office policy for cloning documentation can include the following requirements:
- Data from each encounter should be reviewed for accuracy with the necessary corrections and the provider should add their signature to attest the imported data was reviewed and found to be correct, or necessary modifications were made;
- The chief complaint should be compared with the treatment plan and all issues should be addressed; documentation of the physician work will support the provision of the key components of the E/M service;
- Ensure that copied documentation follows all appropriate organizational, state and federal requirements, including system tracking (audit trails), observing organizational use and testing system capabilities;
- Use of coding professionals or clinical documentation specialists to identify cloning documentation practices when reviewing for completeness of documentation to support coding and billing;
- Create reminders in the system for important red flag questions (e.g., check labs for methotrexate, etc.); and
- Quarterly training and education of documentation rules and guidelines for data/coding accuracy to avoid the risk of cloning.
With the ever-changing pace of new and updated laws and regulations, the task of ensuring that policies are in place to minimize risk can be daunting. But to protect the financial stability of the practice, policies should be created and revised as needed. Remember the EHR is not simply a chart or record, but a system for managing patient care. Proper documentation remains the best means of communicating patient health status and plans of care. Maintaining the integrity of the information through compliance and professional standards is key.
