Pulmonology Coding Alert

CMS approves counting statement in HPI and ROS

Myth: You can't use the same element for both history of present illness (HPI) and review of systems (ROS) unless your pulmonologist notes it twice.
 
Reality: If the physician documents the item clearly, you can count it in both areas. A top CMS official, executive medical officer Barton McCann, said so in a famous 1998 letter to Mason Smith with Lynx Medical Systems in Bellevue, Wash.
 
"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."
 
E/M 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.
 
"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, CHC, CPC, director of reimbursement, HIPAA and fiscal compliance with the Columbia University department of surgery.
 
Example: A patient presents with several problems, including "chest pain with dyspnea."
 
"Chest pain and dyspnea can be counted as location (chest) and associated signs and symptoms (dyspnea) in the history as well as the respiratory section of the ROS," says Patricia Trites with Advocates for Documentation Integrity and Compliance in Augusta, Mich.
 
"People tend to see HPI and ROS as duplications, but they are not," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. "HPI represents factors and details of the chief complaint, while ROS are findings within each organ system that coincide with the presenting problem."
 
Here's how: The patient presents with chest pain, and the physician asks about associated signs and symptoms, determining that the patient does have additional symptoms and counting that as a factor of the HPI. "The details of which organ systems have also been affected by the current problems (such as dyspnea) count toward the system review (ROS)," Pohlig says.

Give Credit for Digging Deeper

Not all carrier medical directors agree with CMS' position on the question of including the same element in HPI and ROS, says Joan Gilhooly, CHCC, CPC, with Medical Business Resources in Evanston, Ill. 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?' " Sandhusen says. Some coders take a more conservative position on this issue because they don't want to have to defend themselves in an audit, he says. 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 use that for both ROS and the chief complaint. "You need to have evidence the physician dug deeper," Gilhooly says.