Outpatient Facility Coding Alert - 2001 Issue 12
The Scoop on Double Dipping: Its OK To Count Systems in Both ROS and HPI
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Article Overview
This premium article explains an emergency department coding controversy involving history documentation for E/M services. It discusses how HPI and ROS are distinguished, how Medicare and carrier policy have been interpreted, and why coders and physicians have debated whether a documented symptom can support both sections. The article is aimed at ED coders, physicians, auditors, and billing staff who need to understand documentation expectations and local policy variation.
Why This Topic Matters
Accurate interpretation of history documentation affects E/M level selection, audit risk, and consistency between provider documentation and coding practice.
Article Sections
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Background on the HPI and ROS debate
Introduces the documentation controversy and explains the two history components involved in emergency department E/M services.
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Medicare policy allows counting a single statement twice
Summarizes the policy interpretation and correspondence discussed in the article, along with broader documentation considerations.
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Complex cases are prime examples
Discusses how the issue is viewed in more complicated emergency department encounters and notes variation in local carrier approaches.
What You Will Learn
- How the article frames the relationship between HPI and ROS in ED documentation
- Why the counting of organ systems across history components has been disputed
- What general Medicare and carrier-policy concerns are discussed
- Why the issue is especially relevant in more complex ED encounters
Who Should Read This
- Emergency department coders
- Physicians
- Billing staff
- Compliance personnel
- Auditors
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