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.