12 Apr Off
While providers and coders work together in the health-care field, there are notable differences between the clinical and the coding worlds. Providers are not always aware of every coding guideline, and this can sometimes result in documentation that is not as specific as needed for coding purposes. This lack of specificity can cause confusion at times. An example of this is documenting current and historical conditions in the medical record. It is a longstanding practice for providers to use the term ‘History of’ when referring to a patient’s past conditions, whether the condition is currently present or historical in nature.
ICD 10-CM guidelines categorize History codes as those that are resolved. History codes (Z77-Z99) may be necessary when the historical condition has an impact on current care or if the condition influences treatment. Capstone Performance Systems advises providers to document “History of” only when the condition no longer exists and it is not being treated or addressed. This practice will ensure better care, more specific coding and better compliance. For example:
- “History of Huntington Disease” when documented as such, means the coder must use the code for a personal history of disease of the nervous system (Z86.69). Even though we know this is an incurable disease, it must be coded as historical instead of as an active disease. Documentation should reflect an active disease to be coded as such.
- “History of Afib” when documented, yields a code for personal history of disease of the circulatory system (Z86.79). If this condition is controlled with treatment such as medication, it should not be documented as historical. This should be documented as a current condition that is actively being treated.
When reviewing documentation, coders cannot make decisions or assumptions regarding that documentation, nor can they fill in the blanks. Providers must be clear and concise in their documentation, so that conditions may be coded to the highest specificity.
Certain disease processes that are no longer active, but require ongoing monitoring or maintenance treatment, such as depression, drug dependence and certain cancers, may be documented as “in remission.” Documenting these conditions requires a provider to exercise clinical judgment; a remission code can be assigned if the condition is specifically documented as such.
Understanding the variances between documentation and coding enables provider and coder to work together towards the goal of accurate coding. Moreover, such collaboration will help to eliminate confusion and lead to better documentation and improved compliance.
Wendy L. Myers CRN-C
Risk Adjustment & Coding Specialist