Wiki Encounter for allergy pt doesn't have?

rtxmc2022

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So basically, pt presents to provider for “penicillin allergy evaluation.” Pt describes a reaction he claims he had as a child and based on this provider determines that pt isn’t allergic. The reaction was just some swelling and a rash at the admin site. Provider says that pt can be “de-labeled” as allergic just based on history and without any further testing. The provider says that this is a “false penicillin allergy,” but he also mentions the possibility that pt HAD a penicillin allergy but outgrew it.

My problem is that I’m struggling to figure out what kind of encounter this would be. Z01.82 doesn’t feel right because there was no testing done. Z03.6 seems to be the most accurate, but it reads like it’s indicating a current adverse effect; this pt is describing something from over 50 years ago.

I’m most likely overthinking it and confusing myself, but if anyone could give me some advice on this one, I’d appreciate it!
 
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