Wiki History of diagnosis

[KoBee]

Aren't you supposed to capture all history of diagnoses as a secondary dx even though the provider does not document them in their MDM? especially during their annual preventive visit and/if it impacts current care or treatment plan.


Help :/

 

[TThivierge]

Kobee
I was taught to add history code if apply to current problem& documented. So let us say patient currently come in for rash, but provider mention 2 years ago had skin cancer..then I d add Z dx code of Z85.828.If pt has ongoing chronic cardiac and lung or ear or gastro problems but current smoker I d add dx Z72 or F17 block and if past smoking history Z87.891. Yes if impacts current care like the smoking dx codes add it. Also it seems on OP side can have 8 dx code, most payers look at first 4 dx. However if given to me in current med record I add them if impacts care or had same problem in past. Also if pt suffers with any T.O.A.D. issues ...list it if impacting care. Transplants, Ostomies, Amputations, Dialysis=all Z dx codes
I hope helped you
Lady T