mony94803
Contributor
E/M Guidelines
I have a encounter that states:
HPI: Patient complains of chest pain for 2 weeks which is dull in nature. No SOB
Can I count chest pain twice? One element for location in HPI and one element for Cardiovascualr ROS? I'm really confused as searching on the web states yes we can double dip and others state we can't.
Palmetto website states "Documentation cannot be used twice uner the History Component. This is referred to as "double dipping". Example: Allergies may be used under the ROS(Allergic/Immunolgic) or under past history".
Does the term "History Component" mean all components? (i.e. CC, HPI, ROS and PFSH). Do you know where I can get an answer?
Thanks
Simone Shofner, CPC:
I have a encounter that states:
HPI: Patient complains of chest pain for 2 weeks which is dull in nature. No SOB
Can I count chest pain twice? One element for location in HPI and one element for Cardiovascualr ROS? I'm really confused as searching on the web states yes we can double dip and others state we can't.
Palmetto website states "Documentation cannot be used twice uner the History Component. This is referred to as "double dipping". Example: Allergies may be used under the ROS(Allergic/Immunolgic) or under past history".
Does the term "History Component" mean all components? (i.e. CC, HPI, ROS and PFSH). Do you know where I can get an answer?
Thanks
Simone Shofner, CPC: