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Coder and Coder2 -- help?! - Coding student

Posted: Sep 21, 2013

I am grappling with something in my mind. Can you clarify it for me? What would be the difference between a late effect and a past history when you are coding? In my book they say "Leg pain resulting from old fracture" or "Intellectual disability due to previous poliomyelitis". And that's obviously a late effect. But in my mind, I just can't see doctors telling you that so prettily and obviously. How do you know if something is a late effect in a chart, I guess? Are you looking for a "due to" or "resulting from", or are you just looking for things that you know in your mind are caused by other things. Did that make sense?

Late effects - Coder2

[ In Reply To ..]
It always depends on how it is documented. Yes, definitely due to or resulting from. You would not code it as a late effect unless they phrased it that way in some way. Patient has aphasia due to stroke, or patient has some residual condition due to a prior injury. Once again, check the guidelines. You will get a feel for it. Late effects will be called sequelae in ICD-10 and that is what they are: a condition that is the consequence of a previous disease or injury. To be coded as such only if said so by the physician.

Late effect vs past history - Coder

[ In Reply To ..]
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.

Thank you both!! - coding student

[ In Reply To ..]
So it sounds like if the physician does not specify that X is a late effect of Y, and I suspect that it is, I should query the physician for more information. I do think the "history" is confusing, especially as being a former transcriptionist I know that the physicians use that "history of" for everything. History of diabetes, history of polio -- everything is "history of" whether they actually got over the illness or not.

History of - Coder

[ In Reply To ..]
In your course, you should not have to query. You can't after all. Same on certification exams. When working, you can accept a variety of language that communicates late effect. Physicians do not usually use the term late effect, but will say due to, from, secondary to, because of, etc.

Physicians use history of to mean someone has had something a while now, as well as had it in the past and no longer does. Pretty much anything that they already knew about is historical knowledge, so the patient has a history of it. If you think about these, you can tell which are still ongoing and which are not.

Of course, you aren't going to be coding all of those historical conditions, the ones that the patient no longer has, so you don't really need to worry about this much. You cannot force them to use the language you prefer, either. They aren't *wrong,* after all. They just aren't using the same definitions you are.

I don't think you will have too much trouble with this. If you are an MT, you have had enough exposure to medical reports that you know what they mean.

Thanks! - coding student

[ In Reply To ..]
I'm just trying to see how all of this works in "the real world". ;)

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