Providers often describe a patient’s past and present health as the patient’s health history, viewing the patient’s health as a continuum, including the current encounter. Following official coding guidelines, coders consider any condition preceded by
history of as no longer existing - the patient is not receiving treatment for this condition. The condition may require continued monitoring for possible recurrence, but it’s no longer active. Coders are further directed by official
coding guidelines to select a personal history code in these instances.
Premera’s History vs. Active Conditions tip sheet offers examples of key terms and phrases, as well as documentation scenarios, to assist the coder in distinguishing between historical and active conditions. Providers can also benefit learning how their documentation impacts
whether a particular condition – historical or active – is supported. The documentation scenarios included in the tip sheet pertain to common conditions. However, the guidance provided can be applied to additional conditions.
Read the History vs. Active Conditions tip sheet to learn how to appropriately document and code for these conditions.
For more information, email Premera’s Provider Clinical Consultant team.