Medicare Compliance & Reimbursement - 2012 Issue 8
Reader Question: Mistaking the past history for ROS is nothing to sneeze at
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Article Overview
This short article answers a documentation and evaluation-and-management coding question about whether allergy status belongs in review of systems or past medical history. It is aimed at coders, auditors, and clinicians who work with ED documentation and need a quick clarification on how to interpret this specific element for level selection.
Why This Topic Matters
Correctly classifying documentation elements affects evaluation-and-management level reporting and helps reduce coding errors in emergency department records.
What You Will Learn
- How allergy status is categorized within clinical documentation for E/M purposes.
- How this documentation element relates to past medical history versus review of systems.
- Why accurate interpretation of ED note elements matters for level assignment.
- How to avoid a common documentation classification error.
Who Should Read This
- Medical coders
- Coding auditors
- Emergency department clinicians
- Compliance staff
- Revenue cycle professionals
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