My PCP has a habit of documenting a lot of conditions as “history of.” I was told that for a condition like CHF, I can code ICD-9-CM 428.0 when she documents “history of CHF.” Is this correct?

Q:	My PCP has a habit of documenting a lot of conditions as “history of.” I was told that for a condition like CHF, I can code ICD-9-CM 428.0 when she documents “history of CHF.” Is this correct?

A:	No. The term ‘history’ is actually used in two manners by clinicians. In one case, it means the patient had this condition in the past. It can also mean the patient has actually had the condition for some time and is receiving treatment. Technically speaking, the ICD-9-CM code for ‘history of CHF’ is V12.59 From a risk adjusted reimbursement standpoint, it’s beneficial to query the provider for clarification and proper documentation if the condition is active, but perhaps stable, at this time. Read more by visiting our blog: The Top Three MRA Mistakes: How much are these costing your practice? This answer was updated for ICD-10-CM. Read here. Tagged: coding, documenting, history of, history of CHF, ICD-9, MRA