Wiki 'History of' vs Current Condition Diagnosis Coding

[rattyvonratkins]

The subjective diagnosis abstraction part of OP Hospital coding really stumps me sometimes. When a provider puts “history of…” directly in the HPI/assessment (separate from PMH section), do you pick these up as CURRENT diagnoses, or ‘personal history of’ dx codes? I find this very confusing.

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Example: Patient is a 32 y.o. male who has been referred by Dr. Smith for seizures and neuralgia. He has a medical history of diabetes mellitus, esophageal varices, pancytopenia, osteoarthritis, scleroderma, chronic fatigue, insomnia, anxiety, depression, and developmental delay.

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Do I check if the conditions are also listed under PMH and if they are, code them as 'history of'? Or do I go by the medications they are currently taking to see which ones are being treated? Or maybe I'm thinking too hard about it...

Other times, the providers will mention symptoms that happened previously but are no longer present at the current visit. Would that qualify for History of other specified conditions (Z87.898) dx? As you can tell, I'm relatively new to this!

Thanks in advance for any help you can offer!

 

[TThivierge]

Hi Ratty
This is CONFUSING info on how "history of" is used in the documentation. Physican should use a date if the illness is older and non existent but most do not. You will have to read thru medical documentation to see if provider mentions current meds using for the illness, dates of symptoms if given and the HPI mention for the day. Yes also mentioned the history if related to current illness. So as an example patient has skin neoplasm now but 2 years ago provider mentions patient had skin cancer dx Z85.828 be added on claim last. Or the patient is getting vitamin D injection add the definitive dx D64 or E55.9 or pt. has current chest pains R07 dx but has past history of past heart attack 5 years ago add dx. Z86.74. Most Z codes are last on claim unless dx blocks of Z01, Z23, Z51 chem rehab or Z01.89. The ICD10 manual tell you which Z codes can be first listed.
Answering your question it seems the physician is telling you the patient currently suffers with dx E11, I85, D72, M19,R62,R53, G47,F41...looks like chronic problems pt has unless gives you a date of past illness. Sometime the EHR templates will have past medical history list with Z codes and dates. If provider list this under ASSESSMENTS......this will be the current dx. codes you ensure put on claim in order of importance he has listed them. Physician are taught to work /treat most serious illness first and put on claim in order.
I hope helped you
Lady T

 

[amyjph]

History of means the condition no longer exists.
See ICD-10 guidelines: History (of) 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. 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.

In your example above, we would need to see more of the documentation to choose diagnoses. Take the insomnia stated above for example. Does that mean the patient had it in the past but it's resolved and gone or not? We can't tell from that statement, we also don't know if this provider is treating it or not and/or does it impact the care they are providing for this patient? Then we have things like developmental delay and you could use amputation (not stated above just an example). These are things that obviously never go away. You would expect to see aquired absence of whatever limb or body part on every claim if it was documented.
Also, in your example the statement is, "referred by Dr. Smith for seizures and neuralgia." Then it goes on to talk about osteoarthritis. Would it make sense to code OA in this case? Does it impact the care or the treatment for the seizures and neuralgia? Again, we would need to see the full note.

If the provider is documenting these in the assessment did they indicate: M-monitoring, E-evaluating, A-assessing, and T-treatment?

https://www.aapc.com/blog/41212-include-meat-in-your-risk-adjustment-documentation/

The best thing to do is always go by the guidelines. It also depends on the provider type. For example, some specialists won't be treating many of these chronic conditions and may not even mention them as impacting care (even if they do). Whereas, for PCPs I would expect to see more diagnoses. Think about the provider type you are coding for. You also have to go by the documentation in the note for that specific service and what the provider actually documents.

https://www.aapc.com/blog/37089-37089/

While you may be able to do some sleuthing and figure things out, you can't assume or start assigning diagnoses unless the provider states it clearly in their documentation. Using a medication list or assuming from a past history is not something we can do as coders.

 

[amroach68]

Actually, in Risk Adjustment according to CMS.gov instructions, it is permissible to use the medication list or the ROS for "clues" that point to a diagnosis as being active versus historical. If a patient is taking Metformin for instance and it's listed in the Medications section of the note, but the provider only documented 'history of' in the PMH you are safe to assume a query to the provider would result in them acknowledging a need to amend the note to list the diabetes as an active, chronic condition. Risk Adjustment coders may even use the A1C results for presence of diabetes if they are documented in any lab results displayed on the note from an EHR.

Risk Adjustment coding handles the way you can find clues on the chart to assess active or historical conditions a little differently than regular coding does. Neoplasms are classic for being documented and coded as active when they are technically history of - a prostectomy for a patient who had prostate cancer, but the provider documents the diagnosis as active. If the prostate was removed and the patient is not on active treatment, or there is no 'watchful waiting', it's "personal history of" not an active code that should be used.

If the EHR -rendered note discloses a Current Problem List and a PMH, then that also helps point Risk Adjustment coders to whether or not a diagnosis is active.

Symptoms that were present but no longer present are sometimes part of hospital diagnostic workups. Symptoms can be coded inpatient unlike outpatient. So, if the symptoms resolved that indicates a history of situation. I am more of an outpatient setting risk adjustment coder so don't take too much of my word for this, but I do know our providers confuse history of and active quite often.