Patient Cloning…from a Billing Perspective

May 20, 2010 04:57 PM
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Physicians Practice online magazine contains and article, “Solving Your 9 Biggest Billing Blunders” (http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1486/cid/p2rss/page/4.htm), in the May 2010 issue.  One of the nine blunders detailed is called “Cloning Patients.”  This is not the genetic type, but the coding type and is becoming a more common mistake with the increasing use of EHR software.  What is this, how does it happen and what can be done to prevent it?  Well, being aware of it is the first step.

Cloning happens when “…the documentation in every patient’s medical record is worded exactly (or almost exactly) like the previous entries.”  The article notes that this has a lot to do with template designs in a clinic’s EHR.  The end result is patients with similar medical records that raise red flags with payers and auditors.  In the past, when documents were all written by the clinician, even when patients had similar exams, the symptoms, severity of symptoms as well as duration would be noted differently for each.  EHR template automation is a great time-saver and can help reduce medical errors.  The key to using them is to not rely on them for everything.  It is still as necessary to provide the same patient details as were previously provided.  The article points out, “If you’re looking for an electronic medical record to solve your coding worries, understand that there’s no system that can code for you.”

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