decisionhealth Newsletters, decisionhealth - 2011 Issue 11 (November)
Understanding E/M: Steer clear of 'cloned' note traps
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Article Overview
This article reviews documentation integrity issues in evaluation and management (E/M) notes, focusing on repetitive or computer-assisted charting that can trigger Medicare contractor and OIG scrutiny. It is aimed at physicians, coders, auditors, and compliance staff who need a practical understanding of why note content, specificity, and patient-by-patient variation matter in E/M compliance. The discussion covers government attention to cloned documentation, general documentation expectations, and broad strategies for making notes more supportable in an audit setting.
Why This Topic Matters
E/M documentation is a frequent audit target, and repetitive or generic notes can create compliance and payment risk. Understanding the article helps practices recognize documentation habits that may draw scrutiny and support more defensible note creation.
What You Will Learn
- Why repetitive or computer-generated E/M notes can create compliance concerns
- How Medicare contractors and the OIG view cloned documentation
- What broad documentation qualities make E/M notes more supportable in an audit
- Why patient-specific histories, exams, and medical decisionmaking matter in E/M records
- How documentation consistency affects audit defense and continuity of care
Who Should Read This
- Physicians
- Coders
- Medical billers
- Compliance auditors
- Practice managers
- Revenue cycle staff
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