Medicare Compliance & Reimbursement

One MAC goes on record about using the same element twice.

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

You have most likely heard the coding advice that you should never "double dip" and count the same information twice within the History component. But what about using the same information between subcomponents of the History? Read on for details about when you can use the same information twice, and when you can't.

The back story: For years, coders have agreed upon one basic fact -- that when an element (such as shortness of breath) is documented just once in the record, you cannot count it twice within a History subcomponent. However, coders have long debated about whether the same element (again, we'll use the example of shortness of breath), when documented just once, can be used to fulfill a requirement in both the history of present illness (HPI) and the review of systems (ROS).

The defense: In 1998, Barton McCann, MD, who was the executive medical director for HCFA (now known as CMS), faxed a letter to a health services company that requested clarification of this issue. In his letter, McCann indicated that information from a single statement could be used in both the ROS and HPI.

Update: Since McCann's letter, which was written 13 years ago, CMS has not come out definitively to address the issue; so many practices still refer to McCann's letter as the authoritative guidance. In addition, at least one MAC has gone on record to indicate that you can use an element twice in the history section, but not in the same subsection.

When asked on its Web site, "Can you use the systems addressed in the history of present illness (HPI) elements or is that 'double dipping?'" Highmark Medicare (a Part B payer for five states) responded, "ROS inquiries are questions concerning the system(s) directly related to the problem(s) identified in the HPI. Therefore, it is not considered "double dipping" to use the system(s) addressed in the HPI for ROS credit." (www.highmarkmedicareservices.com/faq/partb/pet/lpet-evaluation_management_services.html#15).

For instance: "If the physician documents 'leg swelling,' you can't use it in both the musculoskeletal and skin sections of the ROS, but you can use it in the HPI for the location and also in the ROS for skin," says John Turner, MD, PhD, CPC, an emergency physician in Knoxville, Tenn. "The physician shouldn't have to document that in separate paragraphs for it to be used twice," he adds. 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 Suzan Berman, CPC, CEMC, CEDC, senior manager of coding education and documentation compliance with the UPMC Physician Services Division in Pittsburgh. 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.

"I try not to use something twice and I educate physicians and mid-level providers to try to be thorough in all components," Berman says. "But, if the carrier will use it twice, my more conservative view will still keep the documentation compliant.

Despite the fact that some MACs will allow you to use one statement for both an HPI and ROS element, you may still need to check with payers -- both Medicare and private -- regarding their requirements. "Remember, it is a payer-by-payer issue when it comes to audits," says Barbara Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. "So, being conservative, I try to teach physicians to document each component in the history so we are not forced to double-count an element."