tci ED Coding & Reimbursement Alert - 2012 Issue 8

Reader Question: Mistaking the past history for ROS is nothing to sneeze at

Question: How should we count allergy status in determining the E/M level assigned? The ED physician notes under past history "no known drug allergies" (NKDA) or will list the allergy in his documentation. Can we count that as the ENT or allergic/immunologic system?Virginia SubscriberAnswer: You should not count allergy status as a review of systems element. You should count this information as part of the past medical history. ...

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