Electronic Health Record Copy and Paste – Issue at Hand

EHR Copy and Paste – An Issue?

Healthcare personnel are using the copy/paste function in the EHR systems which are a cause for concern.  It has created a serious compliance and payment problems. The technology allows information to be quickly copied from one document into another with the idea being to reduce the time a physician spends typing.  This copy/paste action is also known as ‘cloning’ . The EHR copy and paste function is leading to fraud and abuse of the EHR system. Here are some of the issues created:

Electronic Health Record Copy and Paste – Issue at Hand

• The Electronic Health Record copy and paste technique is being used to get higher reimbursement by upcoding patients’ medical conditions. Medicare is being overcharged and this abuse is running into millions of dollars.

• Another issue is that as doctors are routinely copying information from one file to another to save time, it may happen that the data they enter is not relevant or even erroneous. A recent article in Healthcare IT News reported on the case of a patient who had a “family history of breast cancer” wrongly entered as “a history of breast cancer”. She almost lost her health coverage because the payer thought she had lied on her initial forms.

• There have been cases when a physician copied information from one patient record into another patient’s record.

According to the inspector general’s office, Medicare has failed to provide proper instructions to the contractors who handle payments on how to ascertain fraud arising from EHR implementation. It also found that up to 75% of hospitals surveyed had no formal policy regarding the use of cloning.

Efforts to Resolve Medical Billing Errors and Fraud

The American Health Information Management Association says that cut and paste is one of the best ways to manage the documentation process. Right now we need to find ways to address the flaws in the Electronic Health Record System. Medicare is proposing the following ways to address this cloning issue:

• Creating better standards and systems for validating electronic health records, which ensures the proposed benefits and at the same time protects taxpayers from fraud and abuse.

• Developing guidelines and systems for Medicare contractors to identify cases of  fraud by closely reviewing changes to specific patient documents.

It is important to educate and alert staff on the appropriate use of the copy/paste function. It can be used for copying patient regular medications, chronic allergies, demographics, problem lists and labs and treatments – if these are ongoing and the same from visit to visits. The use of internal audits is also a tool to help find errors so that they can be corrected right away.

By: Dawn Moreno, PhD, CBCS, CMAA, MTC. Lives in the beautiful Southwest United States and has been an instructor for medical coding/billing for the past 7 years. Interested in quality medical billing training?

Get More Information about Electronic Health Records

Future of Medical Billing and Coding – Electronic Medical Records

AAPC – EHRs and E/M Coding: Warnings, Pitfalls, and Best Practices