General Question for the Week of September 5, 2016

General Compliance Question of the Week

Question:

What is the difference between “history of” and “follow-up” in physician documentation?

Answer:

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.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.