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E/M double dipping

Ahamed Fahath

Best answers
Double dipping means consider one thing for Two or more elements. For example, in documenting an ER encounter for a patient presenting with abdominal pain, documentation of the patient's nausea could be used as an 'associated sign and symptom' (HPI element) for credit in the HPI section, and also in 'gastrointestinal' for credit in the ROS section."
But you have to consider this for any one, ie either for HPI portion or for ROS portion but not for both.
Greater Portland (Maine)
Best answers
To address Ahamed's last sentence, you can take one statement and apply it to both the HPI and ROS. You just can't use it twice within one section. For instance, you can't take "chest pain" and use it in the ROS for both "cardiovascular" and "musculoskeletal". See following article for clarification:

Double Dipping is the coder's version of an Urban Legend. The origin of the term double dipping is the Train the Trainer Conference that HCFA offered in December 1997. An attendee at the conference misquoted the speaker at the conference (then HCFA director, Bart McCann, MD) when she took the comment "cannot use one statement to count as two elements" out of context and wrote an article that was printed in Physician Practice Coder. After receiving some feedback contradicting the quote, PPC later printed a clarification but it is very short and hard to find.
Through conversations with other attendees at the conference (including listening to an audio recording) it has been determined that what was actually intended is that a coder cannot use a single statement to count as two elements within the same component. Meaning that the statement " started yesterday" cannot be considered timing and duration within the same HPI. Or the statement "no chest pain" cannot be used as cardiovascular and musculoskeletal in the ROS.
In an effort to clarify Dr. McCann's intent when he mentioned "double dipping", Mason Smith, M.D. wrote to the Medicare Medical Director for his state asking for clarification about using the same statement for the History of Present Illness and the Review of Systems stating "if a notation is made in the HPI section it logically follows that the system relating to the HPI question was reviewed and should be given credit in the ROS"
The Medical Director responded with:
"It is not necessary to mention an item of history twice in order to meet the guidelines for Review of Systems. Repetition of information or data is not required as long as it is appropriately referred to. Once should be enough."
- John H. Lindberg, MD
When he received the above response he then sent the same letter to HCFA with the response from his local carrier for Dr. McCann's opinion (who is supposedly the source of the double dipping rule). Dr. McCann's response was:
"We agree with Dr. Lindberg that it is not necessary to mention an item of history twice in order to meet the Documentation Guidelines requirements for the ROS. It is important that the information which is provided can be inferred accurately and appropriately by a reviewer to determine level of service and medical necessity."
- Barton C. McCann, MD
All of the above letters are available at www.acep.org.
From Webster's Dictionary: Urban Legend - Function: noun Date: 1979: an often lurid story or anecdote that is based on hearsay and widely circulated as true i.e. the urban legend of alligators living in the sewers. Double Dipping became the rule because some unknown coder told PPC, and PPC told us, and it was passed on from coder to coder as gospel. Just like mainstream urban legends the internet has let the Double Dipping rule go nationwide at the push of a button. The problem is that auditors get their information the same way that we do. They read the national coding magazines and follow the discussions on the internet. As a result, some auditors or carriers have used the bad information to make policy decisions.
"I do not believe that it is necessary to write the same information in two places in order for it to "count" for E/M coding. I simply believe that you should not try to count a single bit of information twice (i.e., count it as both HPI and ROS). For example, if an associated symptom is written in the HPI section, you must decide whether that information was gathered in obtaining a history of the present illness (as defined by CPT) or whether it was obtained as part of a systems review (also defined by CPT). You may count it in either part of the history regardless of where it is written but you may not count it in both places regardless of whether it is written once or twice." I reviewed a letter from Bart McCann (then at CMS) and one from a CMD from another carrier (I can't think of which one it was now) to the ACEP some time ago regarding this issue. If you have more current information from CMS on this topic, I would be happy to review it."
- Deborah Patterson, Texas Trailblazer Medical Director
However, other carriers take the opposing stance.
“I would be willing to accept an element documented as associated signs or symptoms in the HPI as an element of the review of systems. However, in a clearly documented chart it should not be necessary to do so.”
- Stephen Boren, MD, WPS Illinois Carrier Medical Director
In June 2003 a client received this response from WPS the carrier for Wisconsin.“When a provider is establishing the History of the Present Illness (HPI)from a patient, they usually include the pertinent positives and negatives which ordinarily would be part of the ROS. For example, if a doctor is interviewing a patient whose chief complaint is chest pain, questions regarding the character of the pain, what brings it on, what relieves it, if there is SOB, etc.are included in the HPI. For the ROS, the note could say "Cardiovascular: see HPI." So, these questions do not need to be repeated in the ROS to be given credit for them.”
The following is the answer a colleague received from CMS on the letters on the ACEP site about double dipping.
"The review of systems (ROS) is an inventory of body systems obtained through questioning to identify the signs and symptoms a patient has experienced or is experiencing. The review of body systems (ROS) is a further development of the history of present illness (HPI), e.g., HPI = cold with cough X one week; ROS = cough, no expectoration, moderate shortness of breath (SOB), slight fever. The ROS questioning/information gathering indicates there is an additional work effort to expand on the problem identified in the chief complaint and HPI.
There are no requirements that the information should be stated or written in any specific format. For example if a medical record questionnaire form had HPI = cough and the ROS = cough and nothing else or the notes just read "cough" and no further information provided it would be difficult to make any determination as the information is sparse and it doesn't identify work beyond a simple identification of "cough".
I believe the letters between Dr. Bart McCann, formerly with HCFA and Dr. John Lindberg, former carrier medical director in Seattle are not interpreted exactly as they had intended. Dr. Lindberg had been asked if a patient presented in the ER with abdominal pain and the symptom of nausea was documented as an associated sign/symptom (HPI) could credit be given in the HPI section as well as when identified in the gastrointestinal portion of the ROS. Both Drs. McCann and Lindberg concurred by stating that repetition of information or data is not required as long as it is appropriately referred to. Dr. McCann went further by stating that it is not necessary to mention an item of history twice to meet the DGs requirement for the ROS. He stated that "it is important that the information which is provided can be inferred accurately and appropriately by a reviewer to determine the level of service and medical necessity."
Dr. Mason Smith, chair of the American College of Emergency Physicians, who when asked Dr. McCann the original question in 1998 stated "if a notation is made in the HPI section it logically follows that the system relating to the HPI question was reviewed and should be given credit in the ROS".
Therefore, it is reasonable that the information gathered from the HPI and ROS and presented in a single sentence or in a questionnaire format could be acceptable if the key concept as explained above is followed and the repeated item of history helps in determining the level of service and the medical necessity.
Obviously a notation of "cough" and no other information provided would not enable a reviewer to determine medical necessity or a level of service (nor would it be helpful to another clinician in a follow-up visit).
Noting positive findings and pertinent negatives will generally add credence to having asked questions in a review of systems and to determining the level of service reported."
In emergency medicine, coding under the restriction of the double dipping myth has prevented many coders from assigning 99284 or 99285 to charts that should have been coded as such. As Dr. McCann and Dr. Lindberg both stated there is no need for the physician to document that same information twice.
I have been training coders and coding charts based on the documentation and not utilizing the myth of double dipping since ACEP started circulating these letters in 1998. I have used copies of the above letters to convince commercial and Medicare auditors that Double Dipping is a myth. I have acted as the expert witness for a group that had been audited and had to defend the original coding in the charts by explaining that the auditors that the government used were flat out wrong. I sat at the table and explained that there is no such thing as double dipping to an Assistant U.S. Attorney General and investigators from the DOJ and FBI. The case was dropped inside a 2 weeks.
All that being said, this should not be an issue in a well structured medical record. If we look at the levels of history and where the issue of Double Dipping could come into play, a reality check should help a coder make the correct decision. To obtain a problem focused history, the physician only needs to obtain 1-3 elements of HPI information. No ROS (ie, questions about other signs/symptoms) information is necessary and no PSFH information is necessary. An expanded problem focused history is one that looks beyond the presenting problem for more information that will assist the physician in identifying what is wrong with the patient and how to treat it. From a coding perspective, If the physician asks one systems related question to help identify whether the patient has other signs or symptoms related to the presenting problem, this now becomes an expanded problem focused history (it doesn't matter whether they document it under the heading HPI or they document it under the heading ROS). The physician has expanded his information gathering to help assist him in identifying whether the presenting problem is simply a straightforward one, or whether he needs to be looking for more information to determine whether there is something else affecting the patient.
The example from Dr. Smith's letter to Medicare was a patient presenting with abdominal pain where the MD inquired about the presence of nausea. The MD has looked beyond the presenting problem and as such has performed an expanded problem focused history.
If a chart has a documented presenting problem of abdominal pain without additional information an aggressive coder may try to use that single statement as a chief complaint, location in the HPI and a GI ROS to qualify as an expanded problem focused history. This is the type of double dipping that is a problem in an audit situation because there is no indication that the MD has done anything other than identify the presenting problem.