As physicians we frequently document past medical conditions with the phrase “history of…”. An example of this would be:
John Doe is a 54 yr old man with history of congestive heart failure who presents with worsening shortness of breath and increased leg swelling.
Though this documentation makes sense to any physician reading this it is not correct by CMS coding guidelines.
According to CMS coding guidelines “history of…” is referring to a condition that is no longer receiving any treatment.
For example 38 yr old man with a history of right tibial fracture in 1995 now presents with fever cough and expectoration. The history of tibia fracture indicates that the patient is no longer receiving treatment for the tibial fracture and is therefore appropriate documentation.
Another example: Jane Doe is a 67 yr old female with a history of hypertension presents with chest pain and is on metoprolol would not be correct as the hypertension is still being treated with the metoprolol even if it is controlled. This distinction is very important to correctly attribute the severity of illness for your patient.
A common mistake is to use the term “history of CHF…” This should be documented as “known CHF currently compensated..” or uncompensated as the case may be.
On April 27th & May 26th Centegra’s HIM department conducted a presentation Kicking-off ICD-10. Dr. Janowtiz, from BCBS, also presented on May 26th regarding ICD-10. Below are the links to the presentations by Centegra HIM and Dr. Janowitz.
In order to ensure capture of current diagnoses they must be documented within the progress notes AND the discharge summary. Diagnoses pertinent to the current visit must be documented in progress notes and carried through to the discharge summary. Including all diagnoses preceded by the words “ possible, probable, resolved, resolving, suspected, improved, improving, likely”.