AHA Coding Clinic® for ICD-9 - 1987 January - February
Diagnosis Qualified by `History of...'
When the physician's statement of diagnosis at the time of the patient's discharge includes a condition prefaced by the term "History of," the Uniform Hospital Discharge Data Set's definition for "Other diagnoses" must be followed in determining whether the condition is to be coded. The definition for "Other diagnoses" is as follows: All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or length of stay are to be reported. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded...
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Article Overview
This article explains coding guidance for diagnoses described as a patient’s history, including when such statements are excluded, when they may still be reported, and how they are handled in rehabilitation and follow-up settings. It is aimed at coders and other health information professionals who work with inpatient and outpatient documentation and need to interpret physician wording consistently with hospital discharge data rules and follow-up visit conventions. The article also references older ICD-9-CM category-based guidance, coding clinic references, and common clinical scenarios used to illustrate the topic.
Why This Topic Matters
Accurate handling of “history of” terminology affects whether conditions are captured, excluded, or linked to rehabilitation or follow-up encounters. This matters for consistent record abstraction, reporting, and compliant diagnosis selection based on the documented purpose of care.
Article Sections
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General rule for diagnoses qualified by “History of…”
Introduces how physician-documented history language is evaluated against hospital discharge data definitions and current-condition reporting principles.
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When “History of…” is not coded
Covers situations where a past condition or procedure is mentioned only as background information and is not part of the current stay.
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When “History of…” is coded
Describes scenarios in which a history statement reflects diagnoses involved in the current care team’s documentation or management context.
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Rehabilitation-related history statements
Addresses rehabilitation admissions and how certain history statements are handled when the treatment setting is a rehab service, unit, or program.
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Follow-up examination guidance
Explains coding for encounters focused on evaluation after prior treatment when the findings are normal and no recurrence is identified.
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Prior surgical procedures and postoperative status
Summarizes when prior procedures are not reported and when ongoing postoperative status or implanted/altered anatomy may remain relevant to current care.
What You Will Learn
- How “history of” wording is evaluated in relation to current diagnosis coding.
- Which broad encounter types are addressed, including inpatient discharge, rehabilitation, and follow-up visits.
- How prior procedures and postoperative status are treated in relation to current care documentation.
- Which kinds of official guidance and legacy coding references the article discusses.
Who Should Read This
- Inpatient coders
- Outpatient coders
- Health information management professionals
- Clinical documentation specialists
- Coding auditors and educators
Codes Discussed
Code Ranges Discussed
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