The Centers for Medicare and Medicaid (CMS) requires that all treatments it pays for be medically necessary. CMS normally reimburses fairly quickly, then audits submitted claims to detect cases where treatment should not have been authorized. Doctors demonstrate the medical necessity of their claims by submitting, when requested, the documentation on cases that the auditors have flagged. If submitted documentation justifies the treatments paid for, the claim will be upheld. If not, then the government asks for its money back, and fines may be imposed. Frequent violators may also be required to submit their case notes for review prior to payment, greatly slowing the payment process.
The thoroughness, accuracy, and legibility of case notes, as well as placing the practitioners handwritten signature on every page, are some guidelines that CMS auditors use to determine if a claim will be paid or denied. But thorough documentation takes time, and it is suspected that some practitioners may cut corners. One way to save documentation time would be to mindlessly copy case notes from one page or case to another. CMS takes a dim view of this practice.
“They Want Notes, They’ll Get Notes”
Medical necessity is most readily demonstrated by providing notes that indicate that the patient is improving as treatments are performed, until a point of maximum medical improvement is reached. According to CMS, from this point forward, further treatments are either not useful, not needed, or are supportive rather than active, and the government will not pay.
The successive documentation of treatment actions and their effect form a “longitudinal record” of each case. Nearly every case will have a similar overall history (patient presented with x due to reported mechanism of injury; treatments resulted in y; patient was deemed sufficiently improved that no further care for this injury was required, or that no additional benefit could be detected and patient was released to maintenance care). However, every case will also be different and unique. CMS is looking for these differences to make sure the care is worthy of government funding. Bulk copying of notes frustrates this process, and could be taken as an indication of possible fraud. According to an entry on the PalmettoGBA website:
“When documentation is worded exactly like previous entries, the documentation is referred to as cloned documentation.”
“It would not be expected that every patient had the same exact problem, symptoms, and required the exact same treatment. Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information for each unique patient.
“Whether the cloned documentation is handwritten, the result of pre-printed template, or use or Electronic Health Records, cloning of documentation will be considered misrepresentation of the medical necessity requirement for coverage of services.” (Medical_record_cloning).
Enter the Spinner
As more doctors convert their practices to electronic health records, an interesting wrinkle has developed. The computer that stores the record is theoretically capable of making slight changes in records that are cut and pasted from one record to the next. This kind of tool is called a “spinner”. The danger of spinners is that a doctor could create records that appear to describe the progress of a patient, whether or not the treatments and improvements occurred as documented. Another danger is that spinners could tend to hide the scientific proof that Chiropractic really does provide patient relief at moderate cost compared to competitive practitioners. In other words, the use of spinners contradicts evidence-based medicine.
A final possible danger of spinners is that they may not work well. The results can be obvious, and sometimes laughable.
However, spinners are available in many medical records software packages, although they may not be called by that name. It would be attractive to employ these tools in situations when documentation is not current, or in which the practitioner is busy, and keeping detailed notes may get in the way of seeing patients who are hurting.
Nevertheless, it would be wise to clone with care. PalmettoGBA is an official Medicare contractor, and private insurance frequently follows the lead of Medicare. Again, from their website:
“Documentation exactly the same from patient to patient is considered cloned and often occurs when services have a specific set of limited or select criteria. Cloned documentation lacks the patient specific information necessary to support services rendered to each individual patient.”
“Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.”