Ask the Experts: June 8, 2015

Question: How does one code a diagnostic statement of history of schizophrenia? There is a Vcode for history of schizophrenia, but schizophrenia is an incurable condition. Should we just code the condition to V11.0 or should we code it to 295.90?

Answer: The term "history of" is not only used by physicians to refer to conditions that no longer exist, but it also very often used by physicians to refer to conditions that are still present, but have a long history of being present (aka, chronic conditions).  So the coder has to identify clues in the documentation to determine the true nature of the condition.  Oftentimes, the patient being on medication for a condition is sufficient evidence to prove that a condition is still present and should be coded as such.  For your case, I would recommend reporting 295.90 especially if there is documentation of medications that are typically associated with this diagnosis.

- Christina Benjamin, MA, RHIA, CCS, CCS-P

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