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Radiology Coding Alert

Reader Question:

Never Clone Your Notes

Question: In the July article Avoid Common Mistakes When Reporting Special Services, you advised against using preprinted templates with diagnosis codes already filled in. But our practice has separate templates for various conditions. We have one template that covers isodose planning for prostate cancer and another for bladder cancer, etc. Each template has certain blanks, such as the symptoms and diagnosis codes, already completed because these are the same for each patient. Should we stop using these? Virginia Subscriber

Answer: Yes, you should stop this practice. Each note should reflect the exact procedure performed for that particular patient. According to a September 2002 Medicare Sentinel publication by TrailBlazer Health Enterprises LLC (a Virginia carrier), One of the probe reviews found several physicians whose office records indicated they used a computerized documentation program that defaults information from previous entries to successive progress notes. It was noted that some physical examinations were nearly identical on subsequent visits, even when there was a change in diagnosis(es). In addition, multiple patients had the exact same findings upon follow-up visits.

The TrailBlazer publication suggested that such defaulted documentation may cause a provider to overlook significant new findings. Many carriers share a concern that templates will include information that the carrier requires such as covered ICD-9 codes to ensure that their claims are paid, whether or not the patient actually has those conditions.

Having similar diagnosis codes on separate claim forms is fine, as long as the patient actually has the given condition and the patients condition is documented in the medical record. You should never place an ICD-9 code on a claim form or a template simply because you know the insurer will automatically consider the procedure medically necessary. You should always ensure that all of the information on your template and in your chart is documented in the patients files.

Most carriers take the issue of cloned documentation very seriously. CIGNA Medicare (a Part B carrier for Idaho, North Carolina and Tennessee), for example, sent out a special Medical Record Cloning reminder in February 1999 that stated, It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. Cloned documentation does not meet medical- necessity requirements for coverage of services due to the lack of specific, individual information Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.

You should avoid such preprinted information. It may save time, but if it costs you reimbursement, it certainly wont be worth it.

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