Wiki When does condition become "history of"

[lrosselli]

Are there any guidelines for when a condition becomes a "history of?" The ICD-9 Official Guidelines state history of codes explain conditions that no longer exist and are not receiving any treatment but have potential for reoccurence. They they don't specify days, months, or years or a timeframe of when the v-codes would be appropriate. What if a patient had rectal bleeding a few months ago but at the current visit does not have it, and endoscopy is ordered. Should it be coded as rectal bleed or history of?

 

[emcee101]

History of is used when the patient is no longer receiving active treatment for the diagnosis. There is no set timeframe since this can vary widely after the date of initial diagnosis. In your example, the colonoscopy would be coded as hx of since the condition does not presently exist and the scope is being done (I assume) for monitoring purposes. If during the course of the colonscopy the doctor finds that there is still an active bleed, then you should use the "active" diagnosis code as opposed to the hx of.

I worked in urology for years, and we treated a lot of bladder cancer patients. The doctor would do a cystoscopy and resect/fulgrate the tumor so it was no longer present, but the patient would still come back for instillations of BCG medication for the following 6-18 months. During this time even though there was no tumor, they were still receiving treatment for the cancer so we would code with 188.x as opposed to v10.51.

Hope this helps!