Cloning – The Dos and Don’ts

Our industry is full of do this, don’t do that, if you do this it could cause that and if it causes that it could lead to this... with me so far? In 2023 I testified in 7 federal criminal cases tied to 18 U.S.C. §1347 (Health Care Fraud) and in several of those cases there were elements of cloning / copy and paste that prosecutors focused on. In fact, in a few of those cases they played excerpts from The Compliance Guy Podcast and tried to use things I and/or my guests talked about to their advantage to seek conviction of a provider.

One of the most discussed issues is cloning / copy and paste since doing that in the government’s eyes diminishes the value of a service and leads providers to over-coding.

What exactly is cloning? According to CMS “cloning is the practice of[1] copying and pasting previously recorded information from a prior note into a new note, and it is a problem in health care institutions that is not broadly addressed.[16, 17] For example, features like auto-fill and auto-prompts can facilitate and improve provider documentation, but they can also be misused. The medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter. Simply changing the date on the EHR without reflecting what occurred during the actual visit is not acceptable. Using electronic signatures or a personal identification number may help deter some of the possible fraud, waste, and abuse that can occur with increased use of EHRs.[18] In its 2013 work plan, the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG) indicated that due to the growing problem of cloning, its staff would be paying close attention to EHR cloning.[19, 20]”

The MACs also have their definition and thoughts on cloning and its negative impact on coding and billing of services. For example, Palmetto, GBA as recently as August of 2020, opined on the topic as well as “over documentation”. “What Is Cloning? The word "cloning" refers to documentation that is worded exactly like previous entries. This may also be referred to as "cut and paste," "copy and paste" or "carried forward." Cloned documentation may be handwritten, but generally occurs when using a preprinted template or a Promoting Interoperability (PI) Programs electronic record. Promoting Interoperability (PI) Programs electronic records?replace traditional paper medical records with computerized record keeping to document and store patient health information. EHRs may include patient demographics, progress notes, medications, medical history and clinical test results from any health care encounter. While these methods of documenting are acceptable, it would not be expected the same patient had the same exact problem, symptoms, and required the exact same treatment or the same patient had the same problem/situation on every encounter. Authorship and documentation in an EHR must be authentic. Cloned documentation does not meet medical necessity requirements for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.

What Is Over-Documentation? Over-documentation is the practice of inserting false or irrelevant documentation to create the appearance of support for billing higher level services. Some PI Programs technologies auto-populate fields when using templates built into the system. Other systems generate extensive documentation on the basis of a single click of a checkbox, which if not appropriately edited by the provider may be inaccurate. Such features produce information suggesting the practitioner performed more comprehensive services than were actually rendered.” [21][2]

Here's the thing to keep in mind, just because a progress note has similar or even identical information in certain areas of the medical record that does not mean it is cloned. Keep in mind... certain specialties such as pain management, rheumatology, orthopedics, cardiology, etc., treat patients with chronic conditions that rarely change from encounter to encounter unless there is some life altering situation that took place, an exacerbation, or they have a breakthrough based on a treatment modality.

There are only so many ways you can say normal mood and affect, normal gait and station, normal flexion and extension, etc. So, with chronically ill patients we do often see similarities and or identical documentation from encounter to encounter but that doesn’t mean the provider didn’t ask the questions or do the work.

In one case I did at the end of 2023 the prosecutor showed me excerpts of the review of systems and examination but didn’t want the jury to see the history of present illness or the plan of care. During cross the prosecutor would say, “do you see this and do you see that, and aren’t they identical?” My response was “sure, I see that, but let’s take a look at the entire document and you will notice that the History of Present Illness (HPI) and Plan of Care (POC) are very different from encounter to encounter for a number of reasons such as increasing or decreasing a dose, stopping or starting of new meds, ordering of labs or other diagnostic tests, etc.” But, in this case the prosecution was so dug-in, in the case based on their “expert” saying it was cloned even when common sense said it wasn't, they just kept arguing. The great news for the provider was the jury didn’t buy the prosecutions case and they acquitted the provider at the end of the trial on all counts.

The fact is, providers and their staff entering information into a specific date of service need to ensure that if you are copying and pasting information you are clear as to why it is being done. I suggest as a best practice having a general statement in the note that says something to this effect “This note contains copy and paste information from prior visits for this patient. The information carried forward is merely for informational purposes only and plays no role in the intensity of the visit or the actual outcome of the CPT / Evaluation and Management (EM) Service code.”

The final thing I would like to point out is that if there is an exacerbation or acute change in the patient’s condition then we would expect to see all of that relevant information in the medical record. However, just because there is some information carried forward from visit to visit does not mean that the notes are cloned or that the services rendered are diminished in any way.

This is the reason why regularly scheduled audits are so critical for medical providers. For more information reach out to www.thecomplianceguy.com

16 U.S. Department of Health and Human Services. (2012, September 24). [Letter from Secretary Sebelius and U.S. Attorney General Holder]. Retrieved October 15, 2015, from https://www.modernhealthcare.com/Assets/pdf/ CH82990924.PDF

17 U.S. Department of Health and Human Services. Office of Inspector General. (2013, December). Not All Recommended Fraud Safeguards Have Been Implemented in Hospital EHR Technology (pp. 3 and 14). Retrieved September 17, 2015, from https://oig.hhs.gov/oei/reports/oei-01-11-00570.pdf ?

18 American Health Information Management Association. (2009). Electronic Signature, Attestation, and Authorship (Updated). Retrieved October 15, 2015, from https://library.ahima.org/xpedio/groups/public/ documents/ahima/bok1_045551.hcsp?dDocName=bok1_045551

19 U.S. Department of Health and Human Services. Office of Inspector General. Work Plan Fiscal Year 2013. Retrieved October 14, 2015, from https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/WorkPlan-2013.pdf

20? U.S. Department of Health and Human Services. Office of Inspector General. (2013, December). Not All Recommended Fraud Safeguards Have Been Implemented in Hospital EHR Technology. (pp. 3 and 14). Retrieved September 17, 2015, from https://oig.hhs.gov/oei/reports/oei-01-11-00570.pdf

21 Medical Record Cloning, Published 08/03/2020 - Medical Record Cloning Published 08/03/2020

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