Coding and Reporting Personal and Family History in the Outpatient Setting

As a coder, you may wonder why it is so important to be reporting all of those history codes that you see documented in a patient’s medical record. In this coding tidbit, you will see some of the reasons why it is important to be reporting these codes even in the outpatient setting as well as where the documentation should be found before reporting.

In the ICD-10-CM guidelines, you will find an entry just for history codes at I.C.21.c.4. There are two types of history Z codes, personal and family. History codes can be used on any medical encounter regardless of the reason for the visit. A history of an illness may alter what treatment is ordered for a patient, so it is important information to be reporting.

History Categories:

Z80: Family history of primary malignant neoplasm

Z81: Family history of mental and behavioral disorders

Z82: Family history of certain disabilities and chronic diseases (leading to disablement)

Z83: Family history of other specific disorders

Z84: Family history of other conditions

Z85: Personal history of malignant neoplasm

Z86: Personal history of certain other disease

Z87: Personal history of other diseases and conditions

Z91.4: Personal history of psychological trauma, not elsewhere classified

Z91.5: Personal history of self-harm

Z91.81: History of falling

Z91.82: Personal history of military deployment

Z91.85: Personal history of military service

Z92: Personal history of medical treatment

Documentation Location and Requirements

Be aware of Coding Clinic 3rd Quarter 2021 pages 32-33 for clarification on Reporting Additional Diagnoses in the Outpatient Setting: Coding professionals should not assign codes based solely on the diagnoses noted in the PMH, history, problem list and/or medication list. It is important to remember the advice of this coding clinic and not to code a Personal or Family History code from the Past Medical History and Family History sections alone for an encounter. It is the provider’s responsibility to document that the Personal and/or Family History affected the care and management of the patient for that encounter, such as in the History of Present Illness (HPI), Assessment and Plan, Consult note, or Anesthesia evaluation.

Family History

Family history codes are for use when a patient has a family member(s) who has a particular disease that causes the patient to be at higher risk of also contracting the disease. A family history can help a physician recommend treatment to reduce the patient’s risk of disease, provide early warning signs of disease, and help plan lifestyle changes to keep the patient well. The family history codes can help explain the need for a test or procedure and provide the medical necessity for it to be done.

An example of this would be a 25-year-old patient has had a screening mammogram done and it was found that the patient has dense breasts, which can cause problems for the physician in being able to read the mammogram and find any abnormalities that may be present. The patient also has a family history of breast cancer in her mother. She has been sent to have a breast ultrasound to look for any possible abnormalities. You would report the breast density and that would provide the medical necessity for a more extensive test to be done such as the ultrasound. Since this is a screening exam in a young patient, the family history of breast cancer may provide the needed medical necessity for this exam to be done at a younger age than normally recommended, as the American Cancer Society recommends women begin screening at age 45.

Personal History

Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring and screening.

For example, a screening colonoscopy is a procedure that is recommended to be done every 10 years for asymptomatic adults at age 50 years. The guidelines do not apply to adults with a long-standing history of inflammatory bowel disease, genetic syndromes such as familial polyps, a personal history of previous colorectal cancer or benign polyps, a family history of colorectal cancer, or other risk factors. In these cases where a patient has a personal or family history of the above conditions a patient may be recommended to have a screening colonoscopy more frequently than the 10 years and these history codes explain the reason for the more frequent screening test and provide the medical necessity needed.

As you can see, it is very important to report a full picture of the patient’s personal and family history as this provides vital information needed for a physician to recommend needed screening and treatment options for prevention of disease that is present in the family or recurrence of a condition the patient has had. These history codes can also provide the medical necessity needed for the different procedures and treatment provided.

This information contained in this coding advice is valid for OUTPATIENT coding. Coders should follow any additional guidance from their facilities.

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.