10 May Off
By Jan Deyber, CRN-C, and Tiffany Brookshire, BSN, CRN-C
We often see inconsistency in medical records regarding diagnoses as current or historical. Documenting “history of” when referencing a patient’s past medical background is a longstanding practice. Providers may intend a “present perfect” tense – a condition that started in the past and continues in the present. However, in the world of diagnosis coding, “history of” indicates a past (or past perfect) tense; in other words, a condition that no longer exists.
Documenting Past Conditions
Good clinical care requires a record of pertinent historical illnesses; e.g., a condition with known predisposition for recurrence, like cancer, diverticulitis or UTI. Thus, we advise providers to document “history of” only for an illness that no longer exists and is not being treated or addressed.
Certain past conditions that are presently quiescent, such as certain cancers, depression, alcoholism, and drug dependence, should prompt a consideration for documenting “in remission.” These disease processes are often monitored and may require maintenance treatment to keep the condition at bay. “History of” would not be appropriate for a patient who is sober with his alcoholism, for instance.
Some “present perfect” conditions become so familiar to providers for certain patients, that they are no longer perceived as a diagnosis, and may not be routinely documented. Common examples include the “status” of presence of prosthetic devices, amputations, artificial openings, dependence on machines, and major organ transplant.
Coding Past Conditions
At least three categories of ICD-10 codes can be reported for past conditions that have a present impact: a “Personal History” code, a “Status” code or a “Remission” code. These are mostly reported with Z-codes from ICD-10’s Chapter 21 (Factors Influencing Health Status and Contact with Health Services).
“Personal History” sections include Z85 – malignant neoplasm, Z86 – certain other diseases, Z87 – other diseases and conditions, and Z92 – medical treatment. These codes generally do not risk adjust.
“Remission” codes are found with their conditions and generally risk adjust. Common situations include major depression, substance dependence and some malignancies. In particular, categories for leukemia, multiple myeloma and malignant plasma cell neoplasms, have codes indicating remission.
“Status” codes are Z-codes reported for a patient who is either a carrier of a disease or has the sequelae or residual of a past disease or condition. A status code is distinct from a personal history code and some status codes risk adjust because care for the condition is intensive and expensive.
Coding past conditions can cause confusion for providers and for coders. Documentation is the key to clarity for a past vs. current code. Comprehensive and concise documentation is paramount to coding to the highest specificity in ICD-10. Clear documentation of the status of a condition is required to correctly code for a current or “history of” disease process. Because “status” and “remission” conditions impact care and may also risk adjust, providers and coders must give attention and care to them in documentation and coding.