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Repeating documentation for the HPI and ROS, is it allowed?
Question: I read your recent coding column in which "double dipping" came up. What would be considered "double dipping" between the HPI and ROS?
One thing that I find in psychiatry is that the symptoms for a particular diagnosis can cover a lot of systems - for example, depression symptoms include "loss of appetite" -I assume that this counts as a GI ROS item as well. Am I correct?
Answer: The following discussion between a provider and a Medicare medical director is the classic example of double dipping:
Physician: "It is my understanding that a single statement may be used in both the HPI and the ROS, negating the need for a physician to repeat himself. For example, in documenting an ER encounter for a patient presenting with abdominal pain, documentation of the patient's nausea could be used as an 'associated sign and symptom' (HPI element) for credit in the HPI section, and also in 'gastrointestinal' for credit in the ROS section."
Medicare medical director: "It is not necessary to mention an item of history twice in order to meet the documentation requirement guidelines required for the ROS."
Do remember that this is subject to carrier/payer interpretation, and that it sure does make it easier to count if HPI and ROS are separate. You don't want to make it hard on a Medicare auditor.
The second part of your question was about your example: appetite is considered part of constitutional, not GI.
Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at email@example.com or firstname.lastname@example.org.
This article originally appeared in the March 2011 issue of Physicians Practice.