ED Coding and Reimbursement Alert

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 as "an inventory of body systems through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced."

The allergy/immunologic sub-element for ROS would typically involve conditions such as urticaria, itchy eyes, or other allergic symptoms. If the physician asked the patient, "Do you have any allergy symptoms, such as itchy eyes or urticaria?" and the patient answered "No," you should consider that the doctor had addressed the allergy/immunology portion of ROS.

Generally, the purpose of the question about allergies is to find out the patient's past medical history, and doctors usually ask it to find out whether the patient is allergic to medications the physician might prescribe to treat the presenting problem.

A simple notation of "allergies: none" should be more appropriately categorized as PFSH (past family social history) information, not ROS.