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Avoid documentation cloning

November 1, 2019

Medical record reviews conducted by Independence’s Corporate and Financial Investigations Department (CFID) have shown that providers are billing higher levels of evaluation and management services based upon cloned documentation rather than the actual service provided. Cloned notes affect the integrity of the medical record.

What is cloning?

Cloning is when identical or similar documentation is used in a note describing an encounter. Medical records must contain documentation showing specific differences for each visit according to the needs of the patient for that date of service. Electronic medical records (EMR) enable quick access to patient records for more coordinated, efficient care. However, all forms of identical or similar documentation that are defined as cloning are a result of certain EMR features like:

  • copy and paste
  • auto-fill and auto-prompts (overdocumentation)
  • pulling forward
  • macros and/or templates

Medical records reflecting these patterns misrepresent the medical necessity required for reimbursement of services rendered and cause the accuracy of the documentation to be questioned.

Services that show evidence of cloning will not be considered for reimbursement because it is not possible to determine exactly how much work was performed during an encounter. Audit summaries that identify documentation associated with any form of cloning may result in recovery of overpayments.

Learn more

If you have questions about the content of this article, please email our Provider Communications team at provider_communications@ibx.com.


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