Wiki coding "recent"

[mcdream]

Hi all! When documentation only states "recent" do you code as active or history of?
Example: Recent thyroid storm, MNG. Code as E05.21 or Z86.39 (hx of endocrine...disease)
TIA

 

[thomas7331]

The term 'recent', by itself, does not direct to a particular code since it does not tell you whether or not the condition is active at the current encounter. You'd need to look to the physician's documentation and assessment to determine if it is a condition that is still present, needing evaluation and/or under treatment (coded with the diagnosis) or resolved and no longer being treated (coded as history). If it is not clear which is the case, then it would be necessary to query the provider.

 

[Munzueta]

I agree with Thomas,

more information is needed to clarify, but yes, to be able to determine if a condition is active or not , you also want to see if they are still receiving any type of treatment/evaluation. Chronic conditions can be controlled but still active which mean they won't history codes, they will be coded as active conditions, but at the same time what exactly are they treating the patient for?

Marco