Part B Insider - 2013 Issue 7
Reader Question: The Past Is History, So Let's Examine The Present
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Article Overview
This short Q&A article explains how allergy information documented in a patient note is generally viewed for evaluation and management reporting. It is aimed at coders and auditors who need to understand where this type of information fits within the medical record and when it may be relevant to different parts of the encounter documentation.
Why This Topic Matters
Properly interpreting allergy documentation affects E/M level support and helps coders distinguish routine history entries from information that may be clinically relevant to the presenting problem.
What You Will Learn
- How allergy status is generally categorized in an E/M record
- How the same information may be viewed differently when it is relevant to the presenting problem
- How allergy documentation relates broadly to history and exam documentation review
- What kinds of documentation context can make allergy information more significant in an encounter note
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Emergency department documentation reviewers
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