RE: Policy or written guidelines for handling cloned or cut/paste notes
I carry around this document from Medicare contractors, gets right to the point, cloned documentation = no payment for the physician, particuarly troublesome to private physicians, there livelihood depends upon getting paid for the work perform
http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Railroad Medicare~Articles~EM Help Center~8MKQK88358?open&navmenu=Articles||||
Cloning of Medical Notes
Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment.
Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement 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.
I know our nursing staff had to stop doing this after a JCAHO survey so you may look there for guidance. We've not had any luck with getting the copy and paste to stop by physicians and no one but me and medical records tried to change/address the behavior. So now, I'm just waiting for the next JCAHO survey - the hospital will certainly have to listen when they get "dinged" - I hope. If you figure out something that works, please share. I'm sure there are several facilities who would benefit!
Sharon Cole, RN, CCDS
CDI Specialist
254.751.4256
Sharon.cole@phn-waco.org
http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Railroad Medicare~Articles~EM Help Center~8MKQK88358?open&navmenu=Articles||||
Cloning of Medical Notes
Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment.
Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement 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.
I know our nursing staff had to stop doing this after a JCAHO survey so you may look there for guidance. We've not had any luck with getting the copy and paste to stop by physicians and no one but me and medical records tried to change/address the behavior. So now, I'm just waiting for the next JCAHO survey - the hospital will certainly have to listen when they get "dinged" - I hope. If you figure out something that works, please share. I'm sure there are several facilities who would benefit!
Sharon Cole, RN, CCDS
CDI Specialist
254.751.4256
Sharon.cole@phn-waco.org