ED Coding and Reimbursement Alert

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 might appear as an HPI element, such as context or modifying factors, or could be a physical exam element such as throat restricted and difficulty breathing form exposure to say a peanut allergy.