Double Dipping in the History of the Evaluation and Management Note

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Sep 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:

• 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. 

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.

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.