Cracking Down on Clones
By Sally Eggleston, MBA, RT(T)

Does your billing company deliver your practice the reimbursement it’s owed? Do you know everything you need to know regarding reimbursement and the vast array of CMS (Centers for Medicare & Medicaid Services) changes? More than ever, healthcare providers need to stay current on all the issues that radiation and medical oncologists face regarding coding, billing and reimbursement. One issue, for example: implementation of the EHR (Electronic Health Record) and scrutiny of the E/M (Evaluation and Management) procedure codes. Medicare MAC’s (Medicare Administrative Contractors) and commercial payors are performing pre-payment and post-payment reviews of E/M’s—both new patient visits and established patient visits—because of “cloned documentation”.

Payors are finding that the latest EMR/EHRs enable physicians to very easily pull previous information from earlier visits into electronic documents. Physicians may not be performing all aspects of the E/M during the current visit, but the documentation still appears in the electronic medical record. Payors can easily identify this when requesting E/M documentation on the same patient for several visits. When the information is exactly the same and seems cloned, the payor may assume the work was not performed and down code or deny the claim.

The physician must always document the history of the present illness based on the patient's description that day. This information should never be copied from a previous visit. Physicians should only perform the review of system categories that are pertinent to the current visit. Medical necessity is not met if reviews of systems are not pertinent to the visit. The past medical, family and social history can be pulled from a previous note, but only if reviewed with the patient and relevant to the current visit.

Every physician and physician practitioner in the United States bills for E/M procedures. These are easy targets for non-reimbursement—ones that CMS figured out several years ago when they decided to no longer pay for consultations (99241-99245 and 99215-99255) due to providers’ improper coding.

While such monitoring of your E/M documents may seem mundane, payors’ scrutiny has never been closer. Be sure to read your dictated and electronic documents thoroughly to ensure accuracy.

RC Billing clients routinely receive internal reviews of their documentation. We also educate and train your staff on our findings, with the goal of a flawless external review. Enhancing your physician and/or hospital practice—and keeping it compliant—is RC Billing’s specialty. If you would like more information, please contact us at or call 512.583.2000.


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