tci ED Coding & Reimbursement Alert - 2005 Issue 10

Reader Questions: Exclude Allergies Statement From ROS

Question: An 18-year-old patient with a possible broken finger after hitting a wall with his right hand presented in the ED. The documentation states that he had no allergies, physical exam of EPF, and that an x-ray revealed a metacarpal fracture. Does "allergies: none" count as ROS?Hawaii Subscriber Answer: In this case, you shouldn't consider this particular statement about allergies a part of the review of systems (ROS). The statement "allergies: none" suggests that the patient is not allergic to any medications, which is commonly part of the "past medical history" element. The 1995 documentation guidelines define ROS...

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