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-10-CM I50.9 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-10-CM I50.9 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-10-CM code for ‘history of CHF’ is Z86.79 Personal history of other diseases of the circulatory system. 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. Of course, with the popularity of EMRs, most diagnosis codes are selected by the actual clinician, so the confusion about “history of” should be infrequent. Read more by visiting our blog: The Top Three MRA Mistakes: How much are these costing your practice? Tagged: documenting, history of, history of CHF, MRA