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Does anyone know Palmetto GBA's policy on using the symptoms dictated in HPI for both HPI and ROS credit, such as SOB for associated signs and symptoms and also using it for a system credit for ROS. I have read countless articles on the Internet that say that it is not considered double-dipping. One of the doctors that I bill for writes everything in one paragraph with no separation of history elements. I can't seem to find an answer to this on Palmetto's website or any other site on the Internet that would reference Palmetto's policy.
I have researched other posts on this site, and I see that many people insist that it is double dipping, but others are insistent that it is not double-dipping. Some say that different Medicare carriers have different rules, so I am trying to get some information on Palmetto's policy.
Thanks for your help!
Dee
Found this on a website. Any thoughts?
FAQ 1. For documentation purposes under the Medicare guidelines, can a single historical item be credited in both the HPI and ROS? For example, could nausea and vomiting be used as a symptom in the HPI and also be credited as a system (GI) in the
ROS?
Some confusion exists over this issue. While it is true that a single item cannot be used twice within the same section of the history (either HPI, ROS or PFSH), it appears that a single item may be used in 2 separate historical sections. Based on correspondence with CMS representatives, ACEP believes that under the CMS documentation guidelines, the use of a single historical item in both the HPI and ROS is recognized as an acceptable practice. These letters can be viewed on the ACEP web site. As with many aspects of the documentation guidelines, individual carrier variation may exist and members are advised to seek clarification with local representatives.
For example, "Nightly," in the statement 'nightly leg pain' could not be credited for both duration and timing in the HPI. However, in the statement 'chest pain with shortness of breath', "shortness of breath" could be credited as an associated sign and symptom in the HPI and also credited in the Respiratory system of the ROS for the same record.
I have researched other posts on this site, and I see that many people insist that it is double dipping, but others are insistent that it is not double-dipping. Some say that different Medicare carriers have different rules, so I am trying to get some information on Palmetto's policy.
Thanks for your help!
Dee
Found this on a website. Any thoughts?
FAQ 1. For documentation purposes under the Medicare guidelines, can a single historical item be credited in both the HPI and ROS? For example, could nausea and vomiting be used as a symptom in the HPI and also be credited as a system (GI) in the
ROS?
Some confusion exists over this issue. While it is true that a single item cannot be used twice within the same section of the history (either HPI, ROS or PFSH), it appears that a single item may be used in 2 separate historical sections. Based on correspondence with CMS representatives, ACEP believes that under the CMS documentation guidelines, the use of a single historical item in both the HPI and ROS is recognized as an acceptable practice. These letters can be viewed on the ACEP web site. As with many aspects of the documentation guidelines, individual carrier variation may exist and members are advised to seek clarification with local representatives.
For example, "Nightly," in the statement 'nightly leg pain' could not be credited for both duration and timing in the HPI. However, in the statement 'chest pain with shortness of breath', "shortness of breath" could be credited as an associated sign and symptom in the HPI and also credited in the Respiratory system of the ROS for the same record.
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