Patient History = Medical Necessity

In the ICD-10-CM guidelines, there is an entry for only history codes at I.C.21.c.4, and there are two types of history Z codes: personal and family.

History codes can be used on any medical encounter regardless of the reason for the visit. A history of an illness may alter what treatment is ordered for a patient, so it is important information to report. This directly supports the medical necessity of the encounter, which is the overarching criteria to report the outpatient or office visit at all.

Terry breaks it down for us, along with answering a 25-modifier question.

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