Know Double Dipping Etiquette

Although it’s usually coding taboo, at times, it’s proper for legitimate recoupment.

By G.J. Verhovshek, MA, CPC
In the coding world, the term “double dip” has two meanings (neither of which has anything to do with dining etiquette). You might think it’s never OK to double dip, but in some circumstances, you definitely should—or risk leaving legitimate reimbursement on the table.

Double Dip “Don’t”

The first use of double dip means to bill twice for the same item; for instance, by separately reporting a service that is included in another (already claimed) procedure. Such unbundling is prohibited, and—even if done unintentionally—can quickly land you in hot water with payers. This type of double dipping is never OK.
As an example, the Medicare surgical package includes routine post-operative care, including related evaluation and management (E/M) services, within the 90-day global period of a major procedure. If you separately report an E/M visit for when the operating surgeon checks on the patient’s recovery (clearly a service related to the surgery), you would be double dipping on the E/M. That’s a “don’t.”
As a second example, you wouldn’t report a designated “separate procedure” when it occurs during the same operative session and in the same anatomic area as another, more extensive procedure. For instance, if a surgeon performs laparoscopic jejunostomy (44186 Laparoscopy, surgical; jejunostomy (e.g., for decompression or feeding)) with lyses of adhesions, you cannot report 44180 Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure). That’s another “don’t” because the separate procedure designation means 44180 is bundled to the related, more extensive procedure (44186).

Double Dip “Do”

The second meaning of double dip is to use a single statement in the documentation of an E/M service more than once when determining the level of service provided. Contrary to what you may have heard, this type of double dipping can be appropriate, if done correctly.
First, some background: Way back in December 1997, Barton C. McCann, MD, publicly remarked that when selecting an E/M service level, you “cannot use one statement to count as two elements.” McCann was not just any physician: He was executive medical officer of the Health Care Finance Administration (precursor to the Centers for Medicare & Medicaid Services), and his instructions mattered greatly to coders, payers, and health care regulators.
McCann’s intended meaning is that you cannot use a single documented item twice within the same component of the E/M service. For instance, if the physician documents “pain since last Tuesday,” you cannot count that statement in the history of present illness (HPI) as timing and duration. It’s one or the other, but not both. Similarly, if the physician records “no back pain,” you can’t count that statement in the review of systems (ROS) as relevant to both musculoskeletal and neurological body systems.
In other words, you shouldn’t use the same statement twice within the history or within the ROS. That’s your third legitimate “don’t.”
Taken in context, McCann’s pronouncement about the inappropriateness of this type of double dipping was neither sensational nor controversial. Unfortunately, his words were immediately taken out of context and applied much more broadly to reflect a meaning he never intended. Specifically, McCann’s statement was interpreted to mean that a single item could not apply to both the HPI and ROS.
For example, suppose a patient presents with chest pain with dyspnea. Under the mistaken interpretation of McCann’s statement, you would not be able to count the documentation as location and associated signs and symptoms in the history and as relevant to the respiratory system in the ROS.

Setting the Record Straight (Sort of)

McCann later disavowed the twisted interpretation of his words, writing, “You ask if a single statement may be used in the history of present illness and still be counted in the review of systems without actually being written twice …. it is not necessary to mention an area of history twice … to meet the documentation requirements for the ROS.” E/M documentation guidelines are supposed to help you find the correct level of service and “not to be perceived as a burden to the physician,” he concluded (see Medical Newswire for more).
Despite McCann’s clarification, the “you can’t use the same documented item in both the history and ROS” trope spread far and wide, and was repeated so often that it has been accepted as truth. In fact, this (mis)understanding has become one of the greatest coding “urban legends.” And because payers and auditors do have freedom in how they apply documentation guidelines, some have, indeed, chosen to interpret the rules to mean a single item cannot be used in both the history and ROS.
The Truth Part 1: There are no requirements for documented patient information to be stated or written in any specific format. Neither the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services state that you cannot count a single item in both the history and ROS. Nothing in the American Medical Association (AMA) or national Medicare guidelines says so, either. And the man who is mistakenly credited with having said it was so has publicly stated that it isn’t.
Any payer or auditor who continues to insist on the validity of the “double dip urban myth” ought to know better, and should be challenged.
The Truth Part 2: As long as an item is clearly documented, you may count it in both the history and ROS. Repetition of data is not required as long as it is appropriately referred to.
Returning to our earlier example of the patient with documented chest pain with dyspnea, you may count dyspnea as both an associated sign/symptom for the HPI and for respiratory ROS (but you should not count “chest pain” for both cardiovascular and musculoskeletal systems in the ROS).
But (and this is a big “but”), if a patient shows up with only one complaint, you shouldn’t use that single complaint for both the history and ROS. Rather, you should look for documented evidence that the physician dug deeper to find more information to assist him or her in identifying what is wrong with the patient and how to treat it (in other words, you should be sure that the physician truly did provide an ROS).
For example, if the patient presents with abdominal pain, and that’s all the physician documents, you shouldn’t report that single item in the history and ROS. But documentation of “abdominal pain, no nausea” means the physician asked additional questions beyond the presenting problem, which makes using the item in both the history and ROS acceptable.
Similarly, documentation of “cough” alone isn’t sufficient to count for both history and ROS; however, “cough one week, no expectoration, moderate shortness of breath” provides plenty of detail to support both the history and ROS elements.
The bottom line: If the physician looks beyond the presenting problem, performing additional work to expand on the problem identified in the chief complaint and HPI, you may “double dip” and count a single element in both the history and ROS. Doing so is not only legitimate, it may mean the difference between, for example, a level III and a level IV E/M code assignment.

Evaluation and Management – CEMC

G.J. Verhovshek, MA, CPC, is managing editor at AAPC.


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