Medical Record Cloning
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.