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 [...]