tci Medicare Compliance & Reimbursement - 2019 Issue Q4

Documentation: Know the Dangers of Cloned Notes

Hint: Do not assume your EHR is flawless. There’s no denying that the advent and adoption of electronic health records (EHRs) and electronic medical records (EMRs) have streamlined healthcare. For some practices, the convenience the software promises sometimes invites lax documentation procedures, especially if staff are tempted to autofill instead of entering new notes. Details: Payers are on the lookout for cloned notes, or health records that are overly similar (or exactly similar) among patients and encounters. “It’s becoming an issue that you could potentially see costing you a recoupment in your practice,” warns Terry...

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