Vaida Posted Wed 15th of January, 2014 21:37:30 PM
Patient comes in with a chief complaint of a suspicious, changing skin lesion on the back. Provider documents in the HPI that "pertinent negatives include the absence of fever and bleeding skin". However in the ROS section, there is also noted that patient denies fever and bleeding skin. My question is if this is considered double dipping since my provider is counting points for "fever" and "bleeding skin" in the HPI as well as ROS.
Also, if this is considered double dipping, which one - HPI or ROS - should be getting credit for this fever and bleeding skin?
SuperCoder Answered Thu 16th of January, 2014 07:36:57 AM
We cannot count these two items at two different places, it is called double dipping. You can count these in any one area either HPI (associated sign and symptoms) or ROS, but not in both.