Medicare Compliance & Reimbursement

How one statement could rescue your E/M coding levels.

Question: Can you use the same element for both history and review of systems (ROS) if the doctor notes it twice?

Answer: As long as the physician documents the item clearly you can count it in both areas. A top Centers for Medicare & Medicaid Services (CMS) official, Executive Medical Officer Barton McCann, said so in a famous 1998 letter to Mason Smith with Lynx Medical Systems in Bellevue, WA.

"It is not necessary to mention an item of history twice in order to meet the Documentation Guidelines requirement for the ROS," McCann wrote. "It is important that the information which is provided can be inferred accurately and appropriately by a reviewer to determine level of service and medical necessity."

Evaluation & management documentation guidelines are supposed to help you find the correct level of service and "not to be perceived as a burden to the physician," McCann concluded. You can also find a carrier article on this topic at www.cms.hhs.gov/mcd/viewarticle.asp?article_id=16555&article_version=2&show=all.
 
"Between the now-famous letter from Bart McCann and the guidance available on the CMS Web site," you should be able to defend using the same statement in both history and ROS, says Eric Sandhusen, director of reimbursement, HIPAA and fiscal compliance with Columbia University Department of Surgery.

For example: A patient presents with several problems, including "chest pain with dyspnea."

"Chest pain and dyspnea can be counted as location and associated signs and symptoms in the history as well as respiratory section of the ROS," says Patricia Trites with Advocates for Documentation Integrity and Compliance in Augusta, MI.

This issue becomes most controversial in those cases where you need a fourth element in your ROS. In that case, you could consider the phrase "with dyspnea" for your ROS, says Joan Gilhooly with Medical Business Resources in Evanston, IL.

Caution: Not all carrier medical directors agree with CMS' position on the question of including the same element in history and ROS, notes Gilhooly. You should check with your own carrier before following this advice.

"It's worth asking, 'Do I ever want to be in the position to HAVE to defend this practice?'" says Sandhusen. Some coders take a more conservative position on this issue because they don't want to have to defend themselves in an audit, he explains. Don't start "double dipping" unless you're sure you can justify it.

Also, if the patient shows up with only one complaint, you shouldn't go ahead and use that for both ROS and history, Gilhooly warns. After all, the form wouldn't have a space for "none taken" under ROS if you could just take any element from the history and use it for ROS, she points out.

"You need to have evidence the physician dug deeper," Gilhooly adds. So including just "abdominal pain" in history and ROS is probably not okay, especially if that's the only complaint. But including "abdominal pain, no nausea" in ROS is okay, because that shows the doctor asked an extra question, she says.

Important: You also can't use the same statement twice within history or within ROS, says Sandhusen.

Bottom line: You should get out of the mindset of "looking for words or phrases" to stick into boxes, says Gilhooly. Physicians don't always put E/M documentation in the correct area on the visit notes, and the heading doesn't always tell you where it belongs. "I have seen ROS information in the exam section of the note," she recalls, because sometimes the physician will ask questions while he examines the patient.