Late effect vs past history - Coder Posted: Sep 22nd, 2013 - 1:28 am In Reply to: Coder and Coder2 -- help?! - Coding student
Some terms mean specific things in ICD-9. They don't necessarily match medicalese.
History means you had it, got over it, and now it is gone. You can have a history of the flu and of chicken pox.
Late effect means you had something, you no longer have it (you have a history of it), and you have some residual condition or sequela as a result.
So, you had a stroke, got over it, but now have left-sided weakness. You have a history of stroke, and you have a late effect of it, which is the weakness.
Do not confuse history with chronic, continuing conditions, or with status post. You have a history of diseases that have resolved. You have chronic conditions when things go on and on, like diabetes. You are status post procedures. This is not necessarily what physicians say.
When they say history of diabetes, unless it truly disappeared, the patient still has it. He just has diabetes.
When they say history of CABG or stent placement, the patient is status post CABG or stent.
Yes, you look for due to or other wording, and you use your own knowledge. If the wording does not match what you think, or if it is unclear, you ask the doctor to clarify it.
Clear: intellectual disability due to head injury as a child.
Not clear: Intellectual disability. History of head injury as a child.
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