Medicare contractors and OIG are auditing EHR notes as part of their 2012 work plans. Their focus is “cloned” notes which means that an entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries or when the documentation is exactly the same from patient to patient. If an entire note is brought forward from the last visit, there may be parts of the note that are no longer applicable and if they are not removed, the current note no longer has validity to the auditor. The OIG auditor has the right to implement a 100% pre-payment review on a provider. This would mean the Medicare contractor could refuse to pay for any E&M service until it audits every note. According to a Florida Medicare Administrative Contractor (MAC) bulletin, “cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services.” Bringing forward an entire history, ROS, PFSH, etc. opens your note to potential errors, medical necessity flags, and expanded audits.
Contact HCSWNY if you require additional information or would like an internal audit performed.