Learn When and How to Correctly Use Personal History Codes
Refresh your knowledge of the Z codes to accurately report past medical conditions that affect current care. At a glance, the Z00.- to Z99.- range (Factors influencing health status and contact with health services) of the 10th edition of the ICD-10-CM code set covers any aspect of a patient’s history that may affect their health status. While some parts of the Z code range are straightforward — think data like body mass index, blood type, do not resuscitate status, and allergies or resistance to medications — the personal and family history sections present challenges to coders. Confusion may arise when coders lack clarity on whether a patient’s condition is active; coders should only apply Z codes if the patient’s condition is not currently active but may affect their care. Review these scenarios for when it is or is not appropriate to apply a Z code for a patient’s personal or family history of a condition. Brush Up on Personal and Family History Codes The 10th edition of the ICD-10-CM code set includes the Z80.- to Z84.- range for family disease history. Similarly, the following code ranges cover personal disease history: These codes identify a patient’s past medical conditions that have been fully treated or resolved but are still relevant to current care or risk assessment. Use personal history Z codes when the provider documentation supports that the condition occurred in the past, the patient is no longer receiving active treatment, and the provider considers the history clinically relevant to the current visit or risk profile. Review Personal History Coding Examples Say that a patient had breast cancer five years ago, completed therapy, and has no current evidence of disease. Now, the patient presents for their annual screening exam. In this case, the correct code is Z85.3 (Personal history of malignant neoplasm of breast). Do not use Z85.3- if the patient is still undergoing cancer treatment or if the patient’s medical record indicates that the patient is undergoing “active surveillance” for potential recurrence of their cancer. In that case, use the proper code from the C50.- (Malignant neoplasms of breast) set until the provider documents disease remission or resolution. Keep in mind that the phrase “no evidence of disease” is a clear sign that the Z85.- range is appropriate versus the C50.- range. Next, consider a patient with a history of nephrotic syndrome who received a kidney transplant. To properly code a provider monitoring the patient’s kidney function, refer to the Z87.4- (Personal history of diseases of genitourinary system) range and select Z87.44- (Personal history of diseases of urinary system). From there, select Z87.441 (Personal history of nephrotic syndrome). Do not refer to the Z87.4- range if the patient’s disease is still present post-transplant. In that case, use the correct code from the N04.- (Nephrotic syndrome) set to indicate that the patient has active disease. Remember These Tips for Using Z Codes Remember that not every previous or familial condition requires documentation with a Z code. For example, Z87.892 (Personal history of anaphylaxis) is irrelevant for a patient with food allergies who presents to the emergency department after they tripped and hurt their ankle — but it is appropriate if this same patient presents with hives. The key is that the patient’s history of anaphylaxis has no bearing on an orthopedic injury but may influence how a provider manages their current case of hives. Just as it is important to avoid Z code overuse, keep in mind that Z codes help coders tell a patient’s complete story. Let’s return to the example with the breast cancer survivor. The best code for this patient returning for their annual screening is Z85.3, but their relatives will require a different code. This patient’s children may begin cancer screenings at an earlier age than the general population because of their family history. In this case, use Z80.3 (Family history of malignant neoplasm of breast) to help explain why they received a mammography or other screening for breast cancer. When in doubt, always confirm the status of the patient’s condition, and ensure that the provider explicitly links the patient’s historical condition to the current encounter. Ask yourself: Michelle Falci, BA, M Falci Communications LLC
