Template Language Targeted:
Documentation Just Got Harder
By Justin Vaughn, M.Div, CPC
Director of Complaince

10/17/2011

According to one Medicare Part B contractor, doctors will have to be very careful to differentiate their procedure descriptions from patient to patient.  That is, the use of template language, i.e., the same wording for the same procedure, but for different patients, will be scrutinized and possibly used as a  basis to deny the claim. 

Palmetto GBA, the Medicare Part B contractor for WV, VA, NC & SC, has this month issued the following advisory to documenting providers:

When documentation is worded exactly like or similar to previous entries, the documentation is referred to as cloned documentation.

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. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.

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.

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.

Pursuant to the above, it would behoove providers—especially in the aforementioned states—to: (a) re-evaluate the use of template-based wording in their medical records, and (b) whenever possible, use varying verbiage to describe a particular procedure so that the documentation is unique to each patient—even where that procedure is virtually the same in scope and progress each time it is performed (eg, pain injections). 

It is quite possible that other Medicare contractors will promulgate similar instructions in the months ahead.  Accordingly, pain providers everywhere should begin eliminating “template-speak” in their op reports and E/M documentation to the extent practicable. 

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.