ICD 10 coding guidelines are very important to following in diagnosis coding. Same rule has to be followed for coding procedure codes. Many coders are still have confusion in coding multiple ICD 10 codes in a medical chart because they do not the coding guidelines.
In ICD 10, coder have confusion in coding Aftercare and followup codes, ruleout or fall ICD codes, suspected diagnosis codes etc. Yes, all these ICD 10 codes have created lot of confusion in coders mind.
Even Z codes have specific coding guidelines. But, many codes are still not aware of the primary Z codes and secondary Z codes. If all these coding doubts are cleared, coders can easily code the diagnosis codes correctly.
Today, I am again going to clear the confusion which is created by the status and personal history codes. Yes, this is very common doubt in coders mind while coding these scenarios. Let us learn about them in detail.
Difference between Status Codes and Personal history codes
In simple language, Status codes indicates that the patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition.A status code is informative, because the status may affect the course of treatment and its outcome.A status code is distinct from a history code.The history code on the other hand, indicates that the patient has no longer the condition.
In hospital setting, always code the status codes as secondary diagnosis. Because if a patient has a carrier of a disease or has some residual of past disease, then it is important for the physician to take more care of the patient. This increase the treatment work of the patient.
For example, a patient had CABG (Coronary Artery Bypass Grafting) surgery few months back. Now, the patient comes for an gallstone problem to the physician. Now, for hospital setting all the previous and current problem should be taken care for quick recovery of the patient. Hence, the gallstone problem will be primary diagnosis to take care but the status of CABG should be also taken care. Hence, the secondary diagnosis of Z95.1 should also be reported to denote that an extra care was taken because of CABG presence.
Personal history codes clearly explain that the patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring.Family history codes are for use when a patient has a family member(s) who has had a particular disease that causes the patient to be at higher risk of also contracting the disease.
Personal history codes should always be coded with Followup codes Z08 and Z09. As per the coding guidelines, the follow up should be reported primary followed by the history of neoplasm or disease codes.
For example, if a patient has a history of lung neoplasm and visit a physician for a follow up exam, then the coders should report Z08 ICD 10 code primary followed by history of lung neoplasm code.
For followup of other diseases, Z09 is reported primary followed by the history of disease ICD 10 codes.
Remember, the neoplasm or the disease should be completed removed or no long exists for coding history codes.
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