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Steven Meyerson, MD, CHCQM-PHYADV, Member of the ACPA Board of Directors
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19

The “F” Word in the Electronic Medical Record: De-Frauding vs. Documenting

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The current epidemic of copy/paste in documenting patient encounters in the hospital results not only in vacuous and voluminous notes but also another underappreciated consequence: accusations of fraud. 

All insurers, including Medicare, pay for content, not volume in documentation: they pay for the physician’s clinical judgment, not their computer skills. Including copy/pasted material in the medical record that is not identified as such is called cloning. Billing for services based on cloned records is a type of fraud.

So how can copy/paste, which is so common these days - and very easy to do - be a fraudulent activity? The answer is simple: payers pay for content. Content is the information obtained during a patient encounter and the physician’s clinical judgment. In other words, they pay for a physician’s medical expertise in gathering and interpreting patient information. 

Both the Centers for Medicare and Medicaid Services (CMS) and the Department of Justice (DOJ) have repeatedly warned against cloning in the medical record. It is considered fraud because the physicians is billing for something they didn’t do. It is fraud because they are billing for something they just copied. Simply put, it is fraud because copy/pasting isn’t doing; it is just copying. 

The OIG(OIG (Office of Inspector General), the government watchdog agency, has a term for copy/pasting: over-documentation, that is, documentation done to support billing a higher level of care than was actually provided. In other words, over-documentation is “OIG-speak for fraud. 

So since all of our readers– we hope – intend to document and not defraud, how can you be at risk of being a fraudster? Well, because documentation fraud looks like this: 

  1. “Cloning fraud” happens when you copy/forward yesterday’s information without attributing it to yesterday’s note. Copy/pasting isn’t fraud if you document in your current note where you copied it from or you document that you repeated all the activities you are copy/forwarding. Yes, if you copy/paste it, you have to document that you redid the complete review of systems, past medical history, physical exam, etc. and it is unchanged. If you don’t do this – it is fraud.
  2. “Plagiarism fraud” can be unintentional but is also common. Plagiarism occurs when  youwhen you copy/paste information from another physician’s note and do not attribute it to them. So be careful copy/pasting from consults, progress notes, and old discharge summaries. Be especially careful when picking up a new patient that you don’t copy/paste your predecessor’s note without attributing it to them. After all, it is their work, not yours.
  3. “Volume fraud” is when you copy/paste information to support a higher billing code. Again, the OIG calls this “over-documentation” which the DOJ calls fraud. 

Lastly, no one but insurance companies making denials and physicians appealing these denials completely read these extensive but clinically vapid notes. As a physician advisor, I frequently read notes where symptoms worsen but vital signs and “ROS” do not change because only the copy/pasted “subjective” information was edited, leaving contradictory documentation within the note. This makes a denial indefensible, your care open to question, and you subject to a charge of fraud! 

This is a physician and electronic medical record (EMR) problem. So it will require both doctors and computers to get smarter. The computer changes are coming (software developers are aware of this problem) but please remember that the EMR is only as smart as you are. So get smart: don’t clone; don’t plagiarize; don’t over-document –because it is not only dumb, it’s fraud.

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Comments

  • An excellent summation by Dr. Salvatore. In general providers get paid not for what they do, but for what they document they do. Conversely they should not be paid for documenting what they do not do. Knowingly submitting a claim for reimbursement for services not performed is the essence of misrepresentation and fraud. The record is the provider's attestation of their work product inclusive of and limited to the actual work performed. I once posed a scenario to a physician; "Your child went out to play before finishing their household chores. To reinforce the rule of completing chores before play you asked the child to write longhand, "Finish chores before play" 500 times before being allowed to play again. Would you say the child complied and provided a true attestation to their work product if only the first page was original work and all following copies of the first?" Current versions of some EMR's have the functionality of identifying copied text and its original source. Copy forward, copy-paste and all forms of cloning not only poses risk of fraud but also threatens the integrity of the entire medical-legal record.
    12/19/2016 9:29:47 AM
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