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Cloning the Medical Record; Dilated Eye Exam; New Patient Requirements

Cloning the Medical Record; Dilated Eye Exam; New Patient Requirements

Cloning in the medical record

Q: I've read a lot about cloning in the medical record, and the HHS Office of Inspector General (OIG) Work Plan includes comments about increased frequency of medical records with identical documentation. How worried do I need to be about my EHR? How much "sameness" is OK?

A: Medicare carriers and contractors have said that documentation is considered cloned when each entry in the beneficiary's medical record is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary.

Each part of the chart these days has elements that can be generated solely by the EHR, or with elements added by the physician. The chief complaints can be the "labels" or names of the template. If you use these, make sure they match the history of present illness (HPI) content that follows.

The HPI can be made up of a series of queries covering the elements of location, duration, timing, quality, etc. If you use these, make sure they make sense. No one wants to see "duration: 2." Two what? Days? Hours?

The review of systems (ROS) is a routine offender. For instance, inadequate charting might involve: If a physician includes a disclaimer such as "complete 14-point review of systems negative except as noted in the HPI above," and he fails to include the ROS in the HPI; or it is a Level 3 visit and doesn't require a full ROS; or there is a standard ROS blurb that conflicts with something in the HPI.

The physical exam is the second element most frequently cited as a cloning or cut and paste concern. Like the ROS, this information can be significantly out of proportion to the presenting problems. The ROS and exam proportion issue ties directly to the payer position that cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. Payers will tell you that cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services. They would rather see patient specific details than generic documentation to cover a given topic or element of an encounter.

Physicians also need to consider whether the assessment and plan area overstates the number of problems addressed. A long list of codes with no visible management does not meet medical necessity criteria. Medicare has repeatedly said that it wants to see the number, acuity, and severity/duration of problems addressed through the history, physical, and medical decision making, rather than just seeing it in the A/P section of the chart.

The increased frequency of medical records with identical documentation across services appears as a concern in the OIG Work Plan for physicians for the third year in a row. Stress to your providers that this is not idle chatter: There is concern at the federal level that current EHR misuse results in significant overpayments, and it likely is.

Comprehensive ophthalmological codes

Q:  Does the 92014 ophthalmology code require a dilated exam component?

A: The descriptions of the comprehensive ophthalmological codes in CPT say that 92014 often includes as indicated: biomicroscopy, examination with cycloplegia or mydriasis, and tonometry. It does not say that you must dilate for this aspect of the exam. This said, most ophthalmologists seem to recognize the dilated exam as an indicator of the 92014.


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