Health care providers truly appreciate electronic medical record (“EMR”) templates because they make documentation faster and easier. However, abuses such a cloning and “exploding” notes are putting reimbursement and compliance at risk. If too much information is replicated from one EMR to the next, there is very little to distinguish patient encounters, which undermines physician attempts to establish medical necessity — the foundation of Medicare reimbursement — and might implicate quality of care.
Although Centers for Medicare & Medicaid Services (“CMS”) has not adopted a position on templates, the agency has noted that they are supposed to encourage physician documentation, and not do most of the work. The problems with templates have become a hot issue because EMR systems are becoming more popular. Moreover, physicians are constantly working to comply with Medicare’s 1995 or 1997 evaluation and management documentation guidelines. However, experts warn that prepopulated templates and cloning may be too easy to help. Cloning may work for certain elements of the history, but it should not be used for the history of present illnesses, the exam, or the medical decision-making portion.
Medicare carriers do not like the use of so-called “default documentation” because they really cannot tell what kind of work is performed in each encounter if the records are so similar. Also, payers want the documentation to support medical necessity, but it is difficult for physicians to document medical necessity because it is a cognitive process. Carrying forth documentation that is not relevant to what the physician did, through the use of cloning or prepopulated templates, is not eligible to receive payment because it is not medically necessary. The government is becoming increasingly aware of this because EMR is becoming so widely used.
Specific Medicare concerns include the possibility that defaulted documentation may cause a provider to overlook significant new findings, as well as the possibility that the provider’s computerized documentation program defaults to a more extensive history and physical examination than is medically necessary to perform on a given day, and does not specifically set forth new findings and changes in a patient’s condition.
In some instances, prepopulated templates and cloned records hardly appear to describe the patient at all. When a patient goes to see a doctor and the EMR for the visit is cut and pasted from the previous medical encounter, all vital signs, history and physical, and review of systems are carried over from the patient with the intention of updating it.
It is important for physicians to take the time to customize medical records to the greatest extent possible, even in a template system, in order to make it clear to auditors that they are not carbon-copy records. This will allow physicians to benefit from the efficiency of EMR, but also to maintain full compliance with Medicare’s standards. Document the patient’s primary complaint, which should carry through to the physical exam and the history, and that should support decision making and medical necessity.
 Report on Medicare Compliance, May 28,2007.
© 2008 Parsonage Vandenack Williams LLC