Wiki History Code

KaylaRieken

True Blue
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504
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Waukee, IA
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i have a patient that had frequency, urgency, and incontinence. They were put on a medication a couple years ago and now the doctor is saying the patient has a history of these symptoms. Instead of using those diagnosis codes, should I be using Z87.448?
 
This comes down to whether the patient is being maintained on these medications. If the doctor has stopped the meds because the symptoms have resolved then 'history of' is appropriate. Otherwise you need to still code these signs and symptoms as active problems if the meds are being continued.
Providers are notoriously incompetent when it comes to documenting 'history of'. Many will use the term simply when the patient had the problem in the past and still has it now. They see the past as history. Don't take the word 'history' too literally.
 
I agree with Twizzle. If this is outpatient coding please see Section IV. J. of ICD10 CM Coding Guidelines

"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"

One needs to determine if the pt is still on medication to treat or suppress the urgency in that case I would code an actual dx something along the lines of R39.15, otherwise if the condition has passed and the condition of urgency is some how pertinent to the complaint for that encounter, say they are being treated now at this encounter for a UTI (very broad example) warranting the Z code I would use a hx code. If neither of these scenarios are happening, the pt is not on meds to actively suppress the urgency and the hx of urgency is not impacting the care or treatment then I would not capture the hx code or the R code.
 
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