Medicare administrative contractor National Government Services has issued a notice stating that cloned documents from electronic health records likely will result in payment denials, DecisionHealth Daily reports.
EHRs allow providers to use default options, including templates. However, NGS warns that individualized patient notes for each patient are required, and that cloned notes may cause a provider to overlook new information that may result in safety or quality issues.
"[C]loned documentation will be considered misrepresentation of the medical necessity requirement for coverage of services due to the lack of specific individual information for each unique patient," the notice states. "Identification of this type of documentation will lead to denial of services for lack of medical necessity and the recoupment of all overpayments made."
Others--like Ron Sterling of EHR consulting group Sterling Solutions in a post on HITECHAnswers, and otolaryngologist Michael Koriwchak in a post on Wired EMR Practice--have expressed concern about the unintended safety risks associated with EHRs. The Institute of Medicine (IOM) has also weighed in, issuing a report last fall expressing concern about patient safety and health IT and recommending that a watchdog agency be created to monitor adverse safety events involving EHRs.
Other default EHR functions, such as automatic coding features, may also cause providers to bill inappropriately, an issue that the Office of Inspector General has included for the first time in its most recent work plan.
To learn more:
- read the DecisionHealth Daily article
- here's the HITECHAnswers post
- check out the Wired EMR Practice post