With the adoption of EHR and the ease with which one can complete an item with just the click of a button, it concerns me that this might produce upcoding.
Case-in-point...when a patient is seen in our facilities it is always protocol to ask if they have any medication allergies. This is good practice except I wonder if medically necessary for our frequently seen patients whom a medical history is already well known.
This question will always produce one point in either the ROS or we can also use this in our PFSH calculation of the history table for E/M and this can many times change the code to a higher level.
Is there anybody else out there with this same concern? I would love to hear your thoughts on this.