General Question for the Week of September 5, 2016

General Compliance Question of the Week


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.

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