ED Coding and Reimbursement Alert

  ED coders have long argued whether an organ system may be counted in both the history of present illness (HPI) and the review of systems (ROS) portion of emergency department E/M services. Both are components of the history-taking key element, with the HPI covering the development of symptoms that caused the patient to come into the ED, and the ROS an inventory of body systems identifying additional signs and symptoms that the patient is experiencing or has experienced. 
 
For example, a patient arrives at the ED with upper respiratory infection symptoms. When recording the HPI, the physician writes a single note stating that the patient's cough is not productive and that her throat is sore. When faced with this type of documentation, coders wonder if CPT and CMS view the information as restricted to HPI, or if it can also represent a review of the cardiovascular and ENT systems. Further, ED coders question if this information must be listed twice in the medical record before it can be regarded as meeting requirements of both the HPI and ROS.
 
Those who contend the system may not be counted twice believe that doing so represents "double dipping" and pads the service to rationalize a higher-paying code. Conversely, other ED coders believe it is justified, and say those who don't count it twice are downcoding and therefore receiving less reimbursement than they ethically deserve.
 
"This discussion has taken on added significance as documentation for E/M services has come under greater Medicare scrutiny for fraud and abuse," says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. "On one hand, ED physician practices want to be paid for the level of service they provide and document. On the other hand, they are afraid of drawing attention that may prompt an audit."
Medicare Policy Allows Counting a Single Statement Twice
According to Mason Smith, MD, FACEP, chair of the American College of Emergency Physicians (ACEP) reimbursement committee for the past four years and CEO of Lynx Medical Systems, a facility and physician coding and billing service based in Bellevue, Wash., it is perfectly acceptable for a single symptom related to any system to be applied to both the HPI and the ROS.
 
In fact, Smith requested and received written confirmation from both his local Medicare carrier (Transamerica Occidental) and the Department of Health and Human Services several years ago. In his request, Smith asked if "a single statement may be used in both areas, negating the need for the physician to repeat him- or herself. In addition, if a notation is made in the HPI section, it is logical that the system relating to the HPI question was reviewed and should [...]