Coding and Billing

Cloning, Copying & Clinical Plagiarism: Why You Have Probably Done It & What Could Happen As a Result

By Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD

August 4, 2021

Have you ever copied and pasted a template into your practice management system when documenting a patient visit? Did you assume it was OK? If you have done this, you may have committed what is known as cloning, copying or clinical plagiarism. Here is why doing this is a bad idea, and what could happen if an insurance company sees you are doing it.

If we would ask 100 doctors which is more of a problem, testing a patient or documenting the testing of a patient, almost all would answer that the documentation is the problem area. Because of that reality, many doctors are looking for ways to make documentation easier. Some doctors have turned to scribes. That can work effectively with a well-trained scribe. Some have turned to other approaches. It’s within that box of “other approaches” that potential problems lie.i

Since each patient presents with a combination of a chief complaint, different DNA backgrounds, a unique environmental background, and the differences occurring in the interactions between all of this, that leads to the expectation that each patient encounter should be different and, therefore, the documentation of each visit should reflect those differences, not only patient to patient but also patient visit to patient visit.

The practice of trying to reduce the work involved in documenting the current patient record by cloning the old record, using templates that pull old record information forward into the new record, or just copying and pasting old record results into the new record, can be problematic.

First, some third parties strictly forbid this practice. Either your provider manual or the provider relations department should be able to tell you for each third party that you participate in if you can do this or not.

Secondly, one of the Documentation Rules that you should know is old information must be clearly differentiated in the patient record from new information. Copying old information and pasting it in the new record without clearly labeling the old information is a violation of this documentation rule.

A specific problem that can occur from this cloning or copying and pasting approach is when a patient schedules for an exam and a staff member “preps” the patient record for the doctor by moving older information into the new record, but then the patient either cancels the appointment or no shows and the information is not removed from the patient record. If someone looks at the record in the future it appears that a patient visit occurred when it did not happen. Obviously, that is a problem. It gets worse if staff bills for the non-existent exam. That’s fraud.

An auditor’s concern goes sky high when each and every entry in a medical record is worded exactly the same or even similar to previous entries. This is going to lead to the auditor looking at more records and asking more questions. Your goal with an auditor is to have them look at your records, not find any problems, and move on to another office. Documenting the correct way is both the best and only way to ensure this happens.

Clinical plagiarism also occurs when you copy and paste from another doctor’s record and put it into your record as if it was work that you either ordered or performed. Be aware that our Medicare contractors have been directed to identify suspected fraud including inappropriate copying of health information in a patient record.

References
i. Clinical Plagiarism – Is Your Provider’s Documentation Putting Your Practice at Risk? Presented by Jill M. Young Brought to you by Webinar Planet; Email : support@webinarplanet.com Phone No: +1 818 584 2346

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