Wiki Dr. says hx, pt on medicine


Jacksonville, AR
Best answers
This is so coding 101, but yes, still a little gray for me...

Dr says history of diabetes, but is on insulin.
And I see many other examples like that....a history of something, but they're on treatment, so should I code exactly what the Dr. says in his wording like a "history" of it, or code active if they're getting treated (on medicine, etc.)
There's a history of disorder category-this instance would be endocrine...

There are many other examples too though. I see it all the time. I think they're trying to say it's in their medical history...not necessarily that the disorder or diagnosis has ceased, BUT it IS worded that way and there are many history codes to use so...code the active dx if they're on treatment or code history because that's what the Dr. says?

I know it would be best to get to the root of it and talk to the Dr's, but when you have done that option....?
It's been my experience that doctors use the phrase 'history of' incorrectly from a coding standpoint quite often, but then that's why they have us!
I guess I've been taught to look at it as they are the clinicians, I am not, and my coding needs to reflect what they document...just don't want to get in trouble in a audit.
Am I too caught up in exact wording? If it IS one of those chronic conditions as previously mentioned, you would code the active diagnosis right? Can you ever not have CHF anymore? As a non-clinician, how do I know what is reversable and what isn't? I mean, a lot of those things I do know just from being in this field or from what seems to be common knowledge but at the same time, I should be the one deciding if they have the active diagnosis or a history?
history of

If the condition is one that would return if the medication was stopped , it's coded as current. We have providers who also use history of- when they should be using controlled by x med.