tci ED Coding & Reimbursement Alert - 2013 Issue 7

Reader Question: The Past Is History, So Let's Examine The Present

Question: How should we count allergy status in determining E/M levels? The ED physician notes under past history “no known drug allergies” (NKDA) or will list the allergy. Can this also be a physical exam element?Virginia Subscriber Answer: You should not typically count allergy status as a physical exam element. You should count this information as part of the past medical history. If an allergies or an allergic reaction was a key factor in the presenting problem that would be a different story than a statement such as “no know allergies.” In that scenario it...

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