A provider’s note says “history of asthma,” but the assessment show…

Question

A provider’s note says “history of asthma,” but the assessment shows active asthma treatment during today’s clinic visit. How should coding distinguish history versus active disease?

Accepted Answer

Code active asthma rather than a personal-history Z-code when the condition is still present and treated. — “History of” in a sentence doesn’t trump today’s inhaler refill and treatment plan. If asthma is still being managed, code the active disease—history Z-codes are for conditions that are truly gone, not still on the med list.

Answer

Always prefer the history Z-code whenever the phrase “history of” appears anywhere in the note.

Answer

Code both active asthma and personal history of asthma for every treated flare.

Answer

Omit respiratory codes until pulmonary function testing is repeated.

A provider’s note says “history of asthma,” but the assessment shows active asthma treatment during today’s clinic visit. How should coding distinguish history versus active disease?

Short Explanation

Full Explanation