• E-mail
• Print
• RSS

Be aware of cloned documentation

HIM Connection, January 24, 2012

Want to receive articles like this one in your inbox? Subscribe to HIM Connection!

In addition to confirming the validity of diagnoses, RACs and other auditors are reviewing documentation from a quality of care perspective. As hospitals transition to EHRs, many auditors are on the lookout for cloned documentation, often a problem in teaching hospitals and large academic medical centers, says Dinh Nguyen, of Healthcare Compliance Solutions, LLC, in Pasadena, CA. "Auditors look for instances when the attending physician cuts and pastes from the resident's note into his own," says Nguyen. The problem also may extend to nursing progress notes, he says.

CMS requires documentation of each encounter so that the note stands on its own and represents the actual services provided by the attending physician for each date of service or encounter. Data, including vital signs, may not be copied from one visit to the next. CMS states that note cloning raises concerns about the medical necessity of continued hospitalization, says Nguyen.

As coders abstract information from the medical record, they should closely examine documentation across multiple dates of service to determine whether it appears to be the same, says Nguyen. When it is, coders should query treating physicians or work with physician advisors to obtain clarification, he says.

Editor’s note: This tip has been adapted from an article which originally appeared in the January issue of Briefings on Coding Compliance Strategies.

Want to receive articles like this one in your inbox? Subscribe to HIM Connection!

• E-mail to a Colleague
• Print
• RSS
• Archive