Know When Documentation Double Dipping Is Appropriate
Nothing in either the 1995 or 1997 E/M documentation guidelines state that you cannot count a single documented item in both the history and review of systems (ROS)—so called “double dipping.” Nothing in AMA/CPT® or Centers for Medicare & Medicaid (CMS) guidelines says so, either.
If 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. For example, if a patient has documented chest pain with dyspnea, you may count dyspnea as both an associated sign/symptom for the history of present illness (HPI) and for respiratory review of symptoms (ROS).
BUT… You cannot use a single documented item twice within the same component of the E/M service. In the example just cited, for instance, you should not count “chest pain” for both cardiovascular and musculoskeletal systems in the ROS. Similarly, if the provider 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. In other words, you shouldn’t use the same statement twice within the history or within the ROS.
If a patient shows up with only one complaint, do not use that single complaint for both the history and ROS. Rather, you should look for documented evidence that the provider looked deeper, to find more information to assist him or her in identifying what is wrong with the patient and how to treat it.
For example, if the patient presents with abdominal pain—and that’s all the provider documents—you shouldn’t report that single item in the history and ROS; however, documentation of “abdominal pain, no nausea” means the provider 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, but “cough one week, no expectoration, moderate shortness of breath” provides adequate detail to support both the history and ROS elements.
The bottom line is, 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.