Double Dipping in the History of the Evaluation and Management Note

by  Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
September 14th, 2017

There are many rules and guidelines a coder must be aware of when it comes to appropriately selecting an Evaluation and Management (EM) code and avoiding doubling dipping is one of them.  Double dipping occurs when the same information is used in more than one of the subcomponents of history.

The subcomponents of history include:

Let's review how double dipping can occur in the HPI.

The HPI is made up of eight (8) elements:

The HPI is scored based on how many of the eight (8) elements were documented in the patient record.  

But what happens to the note that has more than four (4+) elements in the HPI? If more than four are documented, they don’t increase the score of the HPI at all, but they can be used to increase the Review of Systems (ROS) score, if they are applicable. The ROS is a list of 14 organ systems that the provider reviews with the patient to determine if their problem is also affecting other organ systems. For example, a patient with a chief complaint of a runny nose may also note a sore throat (ENT system), cough (respiratory system), or even a fever (constitutional system).

Some HPI elements can cross over into the ROS better than others. Location and Associated Signs and Symptoms tend to be the best HPI elements to use in the ROS, if applicable, as the information presented there also tends to identify organ systems. 

The example below is divided into three score sheets. The first is an example of a poorly scored history, the second an example of double dipping, and the third, proper scoring to the advantage of the provider. 

EXAMPLE:

HPI:  This established patient has had a fever with sore, scratchy throat and severe headache for the past three days. He has had a little nausea but no vomiting. He said his pain is relieved with cold drinks and ibuprofen.

ROS:  None.

PFSH:  No current medications. No known allergies. Nonsmoker/nondrinker.

Score Sheet 
Poorly Scored - Double Dipping - Correctly Scored
Poorly Scored
HPI Element Documented ROS Documented PFSH Documented
Location: throat, head None None Past Medical: No meds, no known allergies
Duration: past 3 days
Quality: sore, scratchy Social: Nonsmoker/nondrinker
Assoc. Signs/Sx: nausea, no vomiting
Mod Factors: cold drinks & ibuprofen Family: None
Severity: severe
4+ = Extended or 99215 0 = None or 99212 2 of 3 = Complete or 99215
The lowest score in any of the subcomponents determines the overall history score.  The coder here believes that if nothing is identified under the heading of the ROS, it cannot be calculated so the EM code would only qualify for 99212. However, if information pertaining to the ROS is documented anywhere in the history or subjective section of the E/M encounter, it can qualify for calculation; as long as it meets the requirements of "a review of systems" as noted in the E/M guidelines. 
Double Dipping
HPI Element Documented ROS Documented PFSH Documented
Location: throat, head GI: Nausea, no vomiting Past Medical: No meds, no known allergies
Duration: past 3 days
Quality: sore, scratchy ENT: Sore throat Social: Nonsmoker/nondrinker
Assoc. Signs/Sx: nausea, no vomiting
Mod Factors: cold drinks & ibuprofen Family: None
Severity: severe
4+ = Extended or 99215 2 = Extended or 99214 2 of 3 = Complete or 99215
Double dipping is against the rules.  The common double dipping example (above) uses the elements of HPI (location and associated signs and symptoms) for both the HPI and the ROS.  Double dipping may increase revenue by making it possible to qualify for a higher level of history and as such be considered fraud or abuse.
Correctly Scored
HPI Element Documented ROS Documented PFSH Documented
Duration: past 3 days Neuro: Headache Past Medical: No current meds
Quality: scratchy ENT: Sore throat Social: Nonsmoker/nondrinker
Mod Factors: cold drinks & ibuprofen No known allergies Family: None
Severity: severe
4 = Extended or 99215 2 = Exp Problem Focused or 99213 2 of 3 = Complete or 99215
Four HPI elements were reported (instead of all six) and what would have been used as location and associated signs and symptoms was used to report the ROS systems (neuro and ENT).  This calculation allows for two (2) ROS to be calculated.  No double dipping occurred and the history portion of the, which is scored at 99214.

All of a sudden, what looked to be a low level history (99212), which required no ROS, has accurately been coded as a 99213 (locating 2 ROS within the history portion of the note). Remember, that the information contained in the CC, HPI, ROS, or PFSH can be applied to any portion of the history score (as long as it is appropriate to the scoring) and only used once.

Of note, some would say that the statement of "No known allergies" could be calculated as part of the review of systems (ROS). The statement suggests the patient is not allergic to any medications, which is commonly part of the "past medical history" element. The 1995 documentation guidelines define ROS as "an inventory of body systems through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced." As such, in the context of this particular encounter, applying this statement to the ROS would be inappropriate. Even so, we were able to locate two systems reviewed that could be applied to the ROS without concern.

It is important to note that the final EM code code is based on overall scoring in the three key components of history, physical examination, and medical decision making, and with only a few exceptions, if the patient is new or established.

Double Dipping in the History of the Evaluation and Management Note. (2017, September 14). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/double-dipping-in-the-history-of-the-evaluation-and-management-note-28290.html

© InnoviHealth Systems Inc

Article Tags  (click on a tag to see related articles)


Publish this Article on your Website, Blog or Newsletter

This article is available for publishing on websites, blogs, and newsletters. The article must be published in its entirety - all links must be active. If you would like to publish this article, please contact us and let us know where you will be publishing it. The easiest way to get the text of the article is to highlight and copy. Or use your browser's "View Source" option to capture the HTML formatted code.

If you would like a specific article written on a medical coding and billing topic, please Contact Us.


contact

innoviHealth Systems, Inc.
62 East 300 North
Spanish Fork, UT 84660
Phone: 801-770-4203 (9-5 Mountain)
Email:
free demo
request yours today
pricing
for any budget
sign IN
welcome back!