Double Dipping in the History of the Evaluation and Management Note

March 3rd, 2017 - Aimee Wilcox, MA, CST, CCS-P, CPMA

Categories: Evaluation & Management (E/M)

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:

Chief Complaint (CC)
History of Present Illness (HPI)
Review of Systems (ROS)
Past Medical, Family, & Social History (PFSH)

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

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

Location
Duration
Timing
Associated Signs/Symptoms
Context
Severity
Quality
Modifying Factors

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

Brief (1-3 elements)
Extended (4 or more elements)

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, and scored this way, the EM code would only qualify for 99212. However, if information pertaining to the ROS, documented anywhere in the history or subjective section of the E/M encounter 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	Allergy/Immuno:	No known allergies	Family:	None
Severity:	severe	Allergy/Immuno:	No known allergies	Family:	None
4 = Extended or 99215		3 = Extended or 99214		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). Additionally, the allergies, listed under the past medical history can be used to report the ROS of allergy/immunology, as long as they are applicable to the CC/HPI. For example, if the provider were to decide the patient's condition requires a prescription, it would be important to know if the patient has any allergies to medications or other things like eggs, or gluten, which may be contained in the drug prescribed. This calculation allows for three (3) ROS to be calculated. No double dipping occurred and the history portion of the note is scored to a 99214 without any concerns for fraud or abuse.

All of a sudden, what looked to be a low level history (99212), which required no ROS, has accurately been coded as a 99214 (locating 3 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 it is only used once.

It is important to note that the final EM code is based on scoring in the three key components of history, physical examination, and medical decision making and are based on the status of the patient as either new or established.

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