Question history of Covid 19 -z09 and z86.19

joyce

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At what point would you code a history of Covid 19 when no subsequent test is done?
If a pt follows up after 14 days, symptom free, do you automatically resort to history of codes?
 

SharonCollachi

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CMS states that you use "history of" when the patient no longer has the condition.

Status codes indicate that a patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition. This includes such things as the presence of prosthetic or mechanical devices resulting from past treatment. A status code is informative, because the status may affect the course of treatment and its outcome. A status code is distinct from a history code. The history code indicates that the patient no longer has the condition. A status code should not be used with a diagnosis code from one of the body system chapters, if the diagnosis code includes the information provided by the status code. For example, code Z94.1, Heart transplant status, should not be used with a code from subcategory T86.2, Complications of heart transplant. The status code does not provide additional information. The complication code indicates that the patient is a heart transplant patient.

There are two types of history Z codes, personal and family. Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring.

ICD-10-CM Official Guidelines for Coding and Reporting FY 2018Page 92 of 117 Family history codes are for use when a patient has a family member(s) who has had a particular disease that causes the patient to be at higher risk of also contracting the disease. Personal history codes may be used in conjunction with follow-up codes and family history codes may be used in conjunction with screening codes to explain the need for a test or procedure. History codes are also acceptable on any medical record regardless of the reason for visit. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered. The history Z code categories are:Z80Family history of primary malignant neoplasm Z81Family history of mental and behavioral disorders Z82Family history of certain disabilities and chronic diseases (leading to disablement)Z83Family history of other specific disorders Z84Family history of other conditions Z85Personal history of malignant neoplasm Z86Personal history of certain other diseasesZ87Personal history of other diseases and conditions Z91.4- Personal history of psychological trauma, not elsewhere classifiedZ91.5 Personal history of self-harmZ91.81 History of falling Z91.82 Personal history of military deployment Z92Personal history of medical treatmentExcept: Z92.0, Personal history of contraception Except: Z92.82, Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to a current facility.


More here, and better formatted for easier reading: https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2018-ICD-10-CM-Coding-Guidelines.pdf
 
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