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ROS question - History of anemia, Pulmonary

  1. #1
    Default ROS question - History of anemia, Pulmonary
    Medical Coding Books
    Documentation Reads:

    Past Medical History: History of anemia, Pulmonary emboli, prior laminectomy, sleep apnea, peripheral neuropathy, gout, spinal stenosis, cervical and lumbar disk disease, chronic back pain, knee problems.

    Allergies: Demerol, penicillin, Ticlid, Plavix, Lipitor and Norvasc.

    Social History: The patient is mostly in his wheelchair due to chronic back pain. He denies tobacco or alcohol use. He was previously followed by the pain center.

    Family History: Mother and father both deceased, neither doe to coronary vascular disease.

    My question is in regards to the Allergies portion... Would it be appropriate to use the allergies (as listed above) in the ROS for the All/immuno or would you consider this to be part of the past history? All feedback is appreciated.


  2. Default ROS question
    Yes, since you already have past illness and past surgery you can use in the allergy portion in ROS.


  3. #3
    Minneapolis MN
    Since the allergies mentioned are, in fact, historical, I would only use them in the hx portion of the key components. If the patient had presented with an illness or injury where allergies was pertinent, then an indication of the signs/symptoms of an allergic reaction i.e. rash could be used as a ROS. The 1997 documentation guidelines are pretty clear that PFSH include "the patient's experience with illnesses, operations, injuries and treatments."

  4. #4
    I was told, by a reliable source, it would have to be specifically mentioned in the review of systems. Relying on the documentation under the heading of allergies does not count towards the ROS. I was told that would be considered "double dipping."

  5. #5
    This is a tough one. I am personally torn on this because I can see and make arguments for both sides.

    I generally look at it from the point of view, why are they here?

    In this case if the patient is following up on HTN, hyperlipidemia, or a condition that may require antibiotics then these would be pertinent as ROS. I agree with the double dipping piece so you would not be able to use them as past history if you are using them as ROS.

    I would also give credit for MS ROS because of the statement "The patient is mostly in his wheelchair due to chronic back pain.", even though this is under a social history heading it is not social history.

    While headings are nice they are not always used appropriately.

    Just my take on it,

    Laura, CPC, CEMC

  6. #6
    Milwaukee WI
    Default NOT double dipping
    It's NOT double dipping UNLESS you are using this information for BOTH past medical history and ROS.

    Most physicians like to have ALLERGIES listed as a separate heading because it can be truly vital information and they want it easily found and noted. On some notes I'll use this information as past medical history. On other notes I might need it for ROS.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  7. #7
    Default ROS question
    I use it where I need it most. I sometimes use them for ROS, if needed, and sometimes for history, if needed. I do not use them for both on the same note. I read something that indicates this is appropriate, will see what I can find to confirm.

    Found 2 references to allergies and where to use them. Neither says anything specifically. One is from E/M conference at AAPC National in Las Vegas and I have it written down beside the slide that allergies can be used for either. Sorry thats, no help for you.

    The other reference is an article by Raemarie Jimenez on page 35 June 2009 Coding Edge, in the last paragraph it says "A reviewer may argue that an HPI element is a "quality" versus an "associated sign and symptom or other element," or that "no known drug allergies" documentation constitutes an ROS element rather than a past history element. Correct interpretation requires consistency, verifiable references, a logical argument, and ultimately medical necessity."

    Will keep looking. Now you got me wondering which would be appropriate, and if either, where's the consistency in this? Hmmmmm!
    Last edited by Anna Weaver; 10-13-2009 at 05:40 AM. Reason: document
    Anna Weaver, CPC, CPMA, CEMC
    Associate Auditor

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