Wiki Guidelines for when to code a personal history of a drug allergy

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lynnmcd

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Hi all!

So, this is my question: when you see a list of known drug allergies noted in the chart do you always code for them no matter what?

Thanks!

Lynn
 
Per the ICD-10 guidelines: "Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment."

Based on this, I would not code drug allergies from the history list unless the provider had specifically documented in the assessment or plan of care that this allergy had somehow played a role in the treatment for the current encounter.
 
thomas7331 said:
Per the ICD-10 guidelines: "Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment."

Based on this, I would not code drug allergies from the history list unless the provider had specifically documented in the assessment or plan of care that this allergy had somehow played a role in the treatment for the current encounter.
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Thank you! Would you code the present drug allergies? It's possible I am not asking the question correctly. So, if the patient comes into the clinic and the doctor notes that the patient is still finishing a course of antibiotics for a UTI, and they have a known PCN allergy, would I code for that PCN allergy since the UTI has been mentioned as part of the visit notes? The infection hasn't been resolved, but is still technically under treatment.

Thanks so much for helping to clear this up! :)
 
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I would code if it the provider documents that it is being relevant to the presenting problem, but not if it is just listed as part of the patient's history.

There really is no such thing as a 'present allergy' - either the patient is currently having an allergic reaction and is being treated for it, or they have a known history of having had a reaction to something in the past. It's a normal part of every medical record to record medical history, and that should be a factor in most treatment decisions, but if the provider hasn't stated that somewhere in the note, then we shouldn't assume it. (Otherwise we would have to code all of the various history conditions that are in the record that have a corresponding code, not just allergies.) I would only code the history if the physician has noted in their assessment and plan that the allergy has somehow had a role in influencing their treatment choices. For example, a provider may include the drug allergy in the problem list, or may note that the patient's allergy prevents them from using the drug combination that they would optimally use for that problem.
 
thomas7331 said:
I would code if it the provider documents that it is being relevant to the presenting problem, but not if it is just listed as part of the patient's history.

There really is no such thing as a 'present allergy' - either the patient is currently having an allergic reaction and is being treated for it, or they have a known history of having had a reaction to something in the past. It's a normal part of every medical record to record medical history, and that should be a factor in most treatment decisions, but if the provider hasn't stated that somewhere in the note, then we shouldn't assume it. (Otherwise we would have to code all of the various history conditions that are in the record that have a corresponding code, not just allergies.) I would only code the history if the physician has noted in their assessment and plan that the allergy has somehow had a role in influencing their treatment choices. For example, a provider may include the drug allergy in the problem list, or may note that the patient's allergy prevents them from using the drug combination that they would optimally use for that problem.
Click to expand...


OK...that makes perfect sense. Thanks so much for your help!
 
thomas7331 said:
I would code if it the provider documents that it is being relevant to the presenting problem, but not if it is just listed as part of the patient's history.

There really is no such thing as a 'present allergy' - either the patient is currently having an allergic reaction and is being treated for it, or they have a known history of having had a reaction to something in the past. It's a normal part of every medical record to record medical history, and that should be a factor in most treatment decisions, but if the provider hasn't stated that somewhere in the note, then we shouldn't assume it. (Otherwise we would have to code all of the various history conditions that are in the record that have a corresponding code, not just allergies.) I would only code the history if the physician has noted in their assessment and plan that the allergy has somehow had a role in influencing their treatment choices. For example, a provider may include the drug allergy in the problem list, or may note that the patient's allergy prevents them from using the drug combination that they would optimally use for that problem.
Click to expand...

Hi, I have a question.. what if this is for an all code capture project? And they are requesting for allergies to be coded as well.
 
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