Wiki history of DX

[cgifford]

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!!

 

[mitchellde]

The patients History of the MM has no bearing on the rash evaluation unless the provider mentions this as a concern. Therefore it is not part of the exam nor did it enter into the decision making process, so there is no reason for it to be coded for this encounter.