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Medical Necessity and Documentation

October 21, 2013

Anyone who has been through compliance training regarding documentation and coding of physician services has learned that Medical Necessity is the overarching criteria for meeting the Medicare coverage requirements. What does that really mean in this day of Electronic Health Records (EHR)? Practically speaking, it means that regardless of the vigor of your documentation and regardless of the fact that the documentation technically supports the code selection, if the nature of the presenting problem does not support the level of service documented and coded, then the service has been over-coded.

As more EHRs are implemented and providers become more savvy  in ways the EHR can save administrative time, the likelihood of cloning or templating notes becomes increasingly common. Properly used templates are not banned or illegal or even frowned upon. When templates turn into a cloning agent for notes, CMS and the OIG get their dander up. I have performed medical record review for thousands and thousands of charts in the course of my career.  Identical or nearly identical notes for completely different presenting problems have never been so prevalent.

On September 24, 2012, Kathleen Sebelius, Secretary of the U.S. Department of Health and Human Services (HHS) and Eric Holder, the U.S. Attorney General for the Department of Justice (DOJ), issued a letter to five of the largest health care organizations in the country. The letter states in part “there are troubling indications that some providers are using this technology to game the system, possibly to obtain payments to which they are not entitled.” Evidence shows that there is “potential cloning of medical records in order to inflate what providers get paid”.  This letter is another warning shot. “False documentation…is illegal. This practice will not be tolerated. Providers in violation will be pursued.

Take this letter seriously. Review your documentation. Review your EHR templates. Could you be mistaken for a gamer or a cloner? Be careful. Be cautious. Be prudent. Be safe so that you can continue your admirable mission.

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