Certified Inpatient Coding (CIC) Practice Exam

What does the cloning of information in EHRs potentially create, according to the OIG?

1. A clear picture of services provided during the patient's stay.

2. Difficulty in identifying current visit activities, possibly leading to inappropriate charges.

3. Accurate and complete documentation.

4. An easy way for providers to create fraudulent records.

The correct answer is: Difficulty in identifying current visit activities, possibly leading to inappropriate charges.

Cloning of information in Electronic Health Records (EHRs) can lead to difficulty in identifying current visit activities. When information is cloned, it means that the same notes or data are reused across multiple patient encounters. This practice can obscure what actually occurred during a specific visit, making it challenging for healthcare providers to accurately assess the patient’s condition, the services rendered, and the appropriateness of coding and charges for that visit. As a result, important details may be overlooked, and the uniqueness of each visit could be lost, ultimately complicating the billing process. Inappropriate charges may arise if the documentation does not accurately reflect the services provided in that particular patient encounter. This issue highlights the importance of thorough and precise documentation in EHRs to ensure clarity and accuracy in patient records and billing practices.