Wiki Allergy documentation

[twizzle]

I really, really need some advice regarding where allergies belongs in the medical record.
For years I was using the list of allergies as part of the ROS. I attended a webinar or read something quite recently that said that it is incorrect to use it as ROS; it is part of the PMH.
I did some research and this forum provided some advice from a couple of people saying their MCR carrier said allergies is PMH.
I e-mailed FCSO today (Florida MAC) and they say allergies is ROS. They also said "we were unable to find any documentation that identifies allergies should be listed as PMH. All documentation found on CMS shows allergies should be listed under ROS".
Wow...confusing or what?

Anyone any thoughts/reliable sources for this issue. I need to resolve it once and for all. I know my webinar or wherever I read it was from a reliable source. One of my colleagues also remembers hearing it but we cannot remember where. We took note because we had always used allergies in the ROS. After all, you would have to ask the question "are you allergic to anything?" and await a response making it a ROS, but once it's in the record the patient will always be allergic to those listed, but may have developed other allergies which the provider has enquired about.

I guess the real issue is, "where does the allergy documentation come from. The past record or asking the patient?"

 

[Tonyj]

I really, really need some advice regarding where allergies belongs in the medical record.
For years I was using the list of allergies as part of the ROS. I attended a webinar or read something quite recently that said that it is incorrect to use it as ROS; it is part of the PMH.
I did some research and this forum provided some advice from a couple of people saying their MCR carrier said allergies is PMH.
I e-mailed FCSO today (Florida MAC) and they say allergies is ROS. They also said "we were unable to find any documentation that identifies allergies should be listed as PMH. All documentation found on CMS shows allergies should be listed under ROS".
Wow...confusing or what?

Anyone any thoughts/reliable sources for this issue. I need to resolve it once and for all. I know my webinar or wherever I read it was from a reliable source. One of my colleagues also remembers hearing it but we cannot remember where. We took note because we had always used allergies in the ROS. After all, you would have to ask the question "are you allergic to anything?" and await a response making it a ROS, but once it's in the record the patient will always be allergic to those listed, but may have developed other allergies which the provider has enquired about.

I guess the real issue is, "where does the allergy documentation come from. The past record or asking the patient?"

I've attended numerous seminars and webinars and I've seen it used in both scenarios. If counting bullet points and allergies is needed to ascertain a highler level of service in ROS or PMH then it would be used accordingly but not for both scenarios which would be considered by some carriers as double dipping. But, I'd also go by your MAC's guidelines.

Curious to see other responses.

 

[jdibble]

I too have always used allergies in the ROS. Where I used to work and live, we were under Novitas (MAC)- and they instructed us through numerouse webinars that allergies could be used in the ROS (it is listed as one of the bullets!!!) or it could be considered for the history. We would use it where we needed it!

I now live in Florida and fall under FCSO (MAC) and they go by the same guidelines. However, I also do some remote coding for a company on the west coast who is under Noridian (MAC) and this company does not accept allergies under ROS unless the patient states what their symptom is...such as Penicillin causes pt to get a rash. If the doctor asks the patient if they have an allergy and they respond no (NKNA), then they will not accept that as a ROS but it will be considered as personal history under PFSH. I don't agree with this since the ROS is supposed to be pertinent positives OR negatives and by doing it this way they are penalizing the doctor a bullet just because the patient said no. However when I code for them I do it that way and when I code for my job here, I use allergies as ROS, whether the patient has them or not!

So, I would say if your MAC allows allergies for ROS, then I would use it for that!!

Hope that helps!!

 

[twizzle]

Allergies

Thanks to both of you...yes , it is confusing.

I did ultimately find the handout relating to this subject. It was actually "Defining E&M grey areas". I was very suprised how few pages were in the handout.....so much is "grey"!

Anyay it was a webinar from the University of Washington Provider Education Compliance department, but the references they used were cms.gov and the '95 and '97 documentation guidelines which is good enough for me.

Basically they say it can be used either in ROS or PMH (not both obviously) depending on how it is documented. A statement below PMH saying NKDA would have to be PMH. A statement saying "the patient denies any new allergies" in addition to any already documented could be either, depending on where you need it the most.

So, thanks again for your imput. I really dislike that different regions have different interpretations though. At least make allergies(and many other things) the same across the board. The job is difficult enough.