Wiki Billing Hx of Dx


Mechanicsville, VA
Best answers
Patient comes in for lets say a rash, the patient is treated and the doctor bills the diagnosis rash with the E&M service. The patient does have a history of MM, can we also bill the DX Z85.820 for his history along with the rash dx? Even though he was not "treated" for the History Of DX, It was noted the patient has a History of in the progress note. Please advise and if you know where I could find any documentation in black and white regarding this topic please share. thanks so much!!
The 'black and white' on this can be found in the ICD-10 book, in the Official Guidelines for Coding and Reporting section, see Section IV on outpatient coding, paragraph J:

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.

So in your example, if the documentation supports that this history affects the treatment rendered, then it would be coded, but if it's just listed as part of the patient's past medical history, then it would not. I'd note that as an exception, some codes do contain specific instructions to use an additional code for history so in those cases it would be appropriate to include it.