What is considered a “double dip” or “double dipping” ?
Double Dip ?Don?t? – The first use of double dip means to bill twice for the same item; for instance, by separately reporting a service that is included in another (already claimed) procedure. Such unbundling is prohibited, and?even if done unintentionally?can quickly land you in hot water with payers. This type of double dipping is never OK.
Nothing in either the 1995 or 1997 E/M documentation guidelines state that you cannot count a single documented item in both the history and review of systems (ROS)?so called ?double dipping.? Nothing in AMA/CPT(R) or Centers for Medicare & Medicaid (CMS) guidelines says so, either.
If an item is clearly documented, you may count it in both the history and ROS. Repetition of data is not required, as long as it is appropriately referred to.
You cannot use a single documented item twice within the same component of the E/M service. In other words, you shouldn?t use the same statement twice within the history or within the ROS.
If a patient shows up with only one complaint, do not use that single complaint for both the history and ROS. Rather, you should look for documented evidence that the provider looked deeper, to find more information to assist him or her in identifying what is wrong with the patient and how to treat it.
The bottom line is, if the physician looks beyond the presenting problem, performing additional work to expand on the problem identified in the chief complaint and HPI, you may ?double dip? and count a single element in both the history and ROS. Doing so is not only legitimate, it may mean the difference between, For example, a level III and a Level IV E/M code assignment.