For the Week of September 5, 2016
What is the difference between “history of” and “follow-up” in physician documentation?
Using “history of” and “follow-up” as if they are the same is a common documentation mistake.
“History of” is often used to indicate the current clinical indication. However, in ICD-10-CM, “history of” means that the patient has a past medical condition that no longer exists and is not receiving any treatment, but has the potential for recurrence.
“Follow-up” goes along with “history of” because follow-up codes indicate continued surveillance following a completed treatment of a condition, not follow-up during treatment.
“History of” is often used to indicate the current clinical indication. However, in ICD-10-CM, “history of” means that the patient has a past medical condition that no longer exists and is not receiving any treatment, but has the potential for recurrence.
“Follow-up” goes along with “history of” because follow-up codes indicate continued surveillance following a completed treatment of a condition, not follow-up during treatment.
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