Internal Medicine Coding Alert

At coding seminars and discussion groups across the country, this debate has raged. When counting documented elements of the history obtained during a physical exam, can the organ system or body area related to the chief complaint be counted in both the history of present illness (HPI) and the review of systems (ROS)?

For example, a patient presents to his primary care physician complaining of chest pain which started the previous evening. The physician takes a complete history, beginning with information regarding past cardiac problems or symptoms. Can the history related to the cardiovascular system be counted for both the HPI and as one of the systems reviewed?

Some experts have interpreted this as double-dipping, a sure trigger for a Medicare audit and fraud citation. Others have contended that counting both is permitted under AMA and Health Care Financing Administration (HCFA) guidelines. Here are the opinions of the experts we interviewed.

Counting System Twice is Not Double-Dipping

According to her interpretation of information in the Medicare manual and the documentation audit form used by HCFA, the element can be counted in both areas of the history, says Susan Stradley, CPC, CCS-P, a consultant in the healthcare division of the accounting firm Elliott, Davis and Co., Augusta, GA.

The audit form instructs the auditor to Place a check or X next to the systems reviewed in the HPI or in the review of systems section of the record, she says. In addition, the instructions say to select an entry for the ROS [indicated in the chart] in the table below, she says. The options given include:

A. No system addressed, circle none.
B. Only the system related to the problem addressed, circle problem pertinent.
C. Notation all others negative appears, circle
complete.
D. Two to nine systems addressed, circle extended.
E. Ten or more systems addressed, circle complete.

Because the form indicates that the physician might only have reviewed the system pertinent to the complaint, HCFA does feel that physicians should get credit for examining that system under the ROS portion of the history, Stradley believes.

Subscriber benefit: To recieve a faxed copy of the HCFA Documentation Audit Form, call 800/508-2582 and ask for document # ICA4-99.

However, an opinion to the contrary was published in another newsletter and that opinion has been taken as fact by many coders and by some carriers, she continues.

Although she feels her opinion is correct coding, it would be advisable for coders to check with their provider representative to be sure. Some states accept this method of counting the elements, and some do not.

It is important to note that counting the systems twice, once in the HPI and once in the ROS, is not the same thing as taking a particular history element given by the patient and using it twice within the HPI because it fits two categories, Stradley emphasizes.

Determination of the level of HPI assigned depends on the number of elements recorded by the physician when obtaining a chronological account of the current complaint. The elements that should be documented include: location, quality, severity, duration, timing, context, modifying factors and associated signs and symptoms.

In the previous example, the patient indicated that chest pain began the previous night. Depending on the specific situation, that information could either be used to indicate the duration of the illness (since last night) or the timing of the illness (occurring last night), says Stradley.

However, that one statement cannot be used to count for both the elementsduration and timing. That is indeed double dipping, Stradley feels.

Systems Should Not be Counted Twice

To be on the safe side, coders at the University of Pennsylvania Medical System do not count the system reviewed in the HPI in the ROS as well, states Gregory L. Schnitzer, RN, CPC, CPC-H, CCS-P, audit specialist in the universitys Office of Audit and Compliance.

We dont have any official indication from HCFA regarding this, he states. Several different people claim to have letters from individual HCFA officials or carrier representatives, but there has not been an overall statement so far.

Until then, Schnitzer says his office has taken the more conservative approach. Like Stradley, Schnitzer suggests contacting the individual Medicare carrier provider representative and/or medical director to determine their interpretation.

An Interpretation from HCFA

The body system examined for the HPI can also be included in the ROS, but documentation should be expanded to include more than that which reported the original complaint, states Aron Primack, MD, medical advisor for the Center for Health Plans and Procedures at HCFA.

If the patient presents with a chief complaint of a cough, and the physician documents under the HPI, chief complaint-cough, then writes under the review of systems, lungs-cough, no that is not correct, he explains. If the physician documents in the ROS lungs-cough for the past two weeks, without wheezing, that is OK.

Primack notes that this opinion cannot be held true for all situations, but that physicians should use their best judgement and common sense.

When looking at a chart, you would expect to see the system examined related to the chief complaint in the HPI to also show up in the ROS, he states. But, I think that the documentation should be expanded to include more information than what was reported for the HPI.