DOCUMENTATION DISPATCH: Documenting and Coding for Past Conditions

DOCUMENTATION DISPATCH: Documenting and Coding for Past Conditions

  • 12 Apr Off
  • Share

Although we are all in the health-care field, there is significant variance between the clinical and the coding worlds. Providers are not coders, which can result in documentation that can be referred to as “doctor-speak,” not “coding-speak.”  Understandably, this difference can cause confusion, such as when inconsistencies regarding diagnosing current and historical conditions occur in the medical record. It is a longstanding practice for providers to use ‘History of’ when referring to a patient’s past conditions, whether they be current or historical.  However, this does not translate into the coding world.

Wendy L. Myers, CRN-C

ICD 10-CM guidelines categorize ‘History of’ diagnoses 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 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, 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 the way it is documented. 
  • “History of Afib” when documented, yields a code for personal history of disease of the circulatory system (Z86.79). Even though this condition may be being controlled by medication, it must be coded as documented.

Remember that coders cannot make decisions or assumptions, nor can they fill in the blanks.  Providers must be clear and concise in their documentation in order for the conditions to be coded to the highest specificity.

Certain disease processes that were active in the past, but now require monitoring or maintenance treatment, such as depression, drug dependence and certain cancers, may be documented as “in remission.”  These conditions require the provider’s clinical judgement and can only be assigned a remission code if specifically documented as such.  (However, when researched in the coding index, a documented history of drug dependence directs to Dependence, drug, by type, in remission). 

Sharing knowledge and working together allows the clinical and coding worlds to coexist. Additionally, this collaboration will help to eliminate confusion and create better documentation that will improve compliance.

Wendy L. Myers CRN-C
Risk Adjustment & Coding Specialist