Cracking the Code
Coding ‘History of’
There are two types of history: personal history and family history. Family history is important to report because some diseases have a genetic predisposition. For example, female patients with a family history of breast cancer are at a higher risk for developing breast cancer. Family history codes can be found in our ICD-10-CM Alphabetic Index under History/family (of).
Personal history codes are reported if the patient no longer has the disease. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered. We can locate personal history codes in our ICD-10-CM Alphabetic Index under History/personal (of).
History codes have an entry in the ICD-10-CM guidelines. These can be found at I.C.21.c.4. It is important for all coders and auditors to apply these codes when applicable.
Remember, the reason for the encounter (for example, screening or counseling) should be sequenced first and the appropriate personal and family history codes should be assigned as additional diagnoses.