AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2020 Issue 1; Ask the Editor
History of (Resolved) Diabetes Mellitus and Hypertension
A patient underwent bariatric surgery due to morbid obesity, hypertension and type 2 diabetes mellitus. Because of the surgery, the patient had lost a significant amount of weight. The provider documented that the patient was no longer diabetic or hypertensive and discontinued medication. There are no documented manifestations of these conditions in the health record. Would it be appropriate to code these conditions when the provider states “history of” or “resolved”? ...
Subscribe or sign in to view the full article.
Article Overview
This article explains a documentation and coding question involving prior diabetes mellitus and hypertension after significant weight loss following bariatric surgery. It is intended for coding professionals, auditors, and clinical documentation staff who need to understand how provider wording such as history of or resolved affects record interpretation. The discussion focuses on general ICD-10-CM history coding concepts and the distinction between active conditions and resolved conditions in the chart.
Why This Topic Matters
Accurate interpretation of resolved conditions affects problem list accuracy, historical reporting, and compliant ICD-10-CM code assignment. This topic is especially relevant when major clinical change, such as post-surgical weight loss, leads to discontinuation of medications and removal of active diagnoses.
What You Will Learn
- How provider documentation of resolved chronic conditions is interpreted for coding purposes.
- Why post-treatment status and absence of manifestations matter in chart review.
- How history terminology can affect selection of ICD-10-CM history codes.
- How bariatric surgery-related clinical changes can influence documentation review.
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Clinical documentation improvement specialists
- Health information management professionals
Codes Discussed
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com