ED Coding and Reimbursement Alert

You can use the same element for both - for some carriers

The physician has left you copious documentation for the patient's review of systems, but the history of present illness falls one element short of "extended." Take heart - you don't have to downcode.

Many coders think they're breaking a sacred rule by pulling a review of systems (ROS) element for the history of present illness (HPI). But in fact, this is perfectly appropriate.

Get the Facts Straight

According to CMS, physicians do not have to document an element twice just so you can use it for both ROS and HPI, says Becky Stanaland, CCS-P, with SS&G Financial Services in Ohio.

For example, if you see "chest pain with dyspnea" in the physician's notes, you can count the phrase dyspnea as both an associated sign/symptom for the HPI and a respiratory ROS. However, you can't use the same element twice in the same area - so "chest pain" can't count for both cardiovascular and musculoskeletal systems in the ROS. Similarly, you can't use a phrase such as "started yesterday" to count as both timing and duration for the HPI.

Best bet: Don't use a statement twice unless it's absolutely necessary in order to assign the correct level of service, says Todd Thomas, CPC, CCS-P, president of Thomas & Associates in Oklahoma City. Your priority should be painting the clearest picture possible for the insurer in order to get paid appropriately, and that means using the entire record available to you - even if all the information isn't wrapped in a nice neat package.

Bust the Myth of Double-Dipping

"Double-dipping," or using one physician statement to count for two separate elements, "is the coder's version of an urban legend," Thomas says. An attendee at a 1997 conference took this statement out of context and printed it, and the idea has since spun out of control.

Two physicians employed by Medicare (Dr. Bart McCann and Dr. John Lindberg) corrected the attendee's misinterpretation shortly afterward, but the idea had already taken hold - and remains so pervasive that not only are coders undercoding many 99284 claims to 99283 (Emergency department visit for the evaluation and management of a patient ...), but auditors are also jumping on the bandwagon.

"That was a myth that was dispelled but which still may be causing a lot of physicians to lose due revenue," Stanaland says.

Thomas has successfully used the two doctors' letters to debunk the double-dipping myth - and defend the practice's code choices - to federal officials who believed it (and were consequently asking for reimbursement for overpayments their auditors had calculated).

Here's Your Backup

Lindberg, the medical director for Washington state's Medicare Part B, stated in a written response to a query that "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."

McCann, the speaker whose words spawned the debate, stated that he "agree[d] with Dr. Lindberg ... it is important that the information provided can be inferred accurately and appropriately by a reviewer to determine level of service and medical necessity." You can find both these letters online at the Web site for the American College of Emergency Physicians: http://www.acep.org/NR/rdonlyres/3E32AD20-975C-447F-9A44-B2E97902DFC7/0/hpiros_letters.pdf.

Talk to Payers Case-by-Case

Despite the technical correctness of using one statement for both an HPI and ROS element, you may still need to check with payers - both Medicare and private (some states' Medicare carriers do disagree with the correctness of using a statement twice) - regarding their requirements. "Individual carrier directors have the power to interpret the guidelines in their own way," Thomas says.
 
And those interpretations may vary. For example, a carrier medical director (CMD) for Wisconsin Physicians Service said that a clearly documented chart would prevent the need to "double-dip" for HPI and ROS, but conceded that if necessary, the carrier would accept counting one statement for both areas. In contrast, the CMD for Trailblazers in Texas disagrees and will not accept using one statement twice.