Please do not mix up history of, with existing active/current, acute, chronic, causal, concurrent. All diseases do not last forever.
I am a medical coding instructor who is launching into instructional design and technologies. In instructional design and technologies, we strategize to improve instructional processes with appropriate learning theories/strategies, technologies, and relevant activities (Reiser & Dempsey, 2018).
In medical coding, attention to the specific terms and whether stated in context of history of, chronic, acute increases accuracy with the medical coding process as it is not just data entry by words. This is why international classifications of diseases, clinical modification (ICD-10-CM) exists and why ICD-11-MMS is being looked at in the future so more clarity with appropriate causal and concurrent conditions may be documented.
Documentation should be clear so accurate diagnosis and procedure codes can be applied and avoid unnecessary audits or denials.
History of
In the ICD-10-CM manual the term history of, refers to personal, or family history- the condition runs in the family in that it may be hereditary as a member of the family has the condition. The personal history is about the patient having had the condition at some time and is now healed, or free of the diagnosis. See below, the first example shows the history of- either family history of or personal history of, while the 2nd picture is a example- of existing type of cancer that may be active and currently treated for.
example of-history of
Existing/Active/Current malignancy
Acute
In the ICD-10-CM manual and American medical association guide on medical problems, the term acute is related to a recent or new short term medical problem, sometimes described as a sudden onset.
Chronic
In the centers for disease control defines chronic as one occurring over a year or more and require ongoing medical attention or limit activities of daily living or both. Examples of these are heart disease and diabetes. ICD-10-CM manual acknowledges chronic in its subcategories and defaults conditions not stated as acute to chronic. For example CKD and hypertension currently has underlying effects and require combination codes- e.g. hypertension with CKD stage 3b- I12.9, N18.32.
Causal
In the ICD-11-MMS the term causal refers to a condition that is influencing an existing condition whether it is acute or chronic. For example: the same hypertension and CKD stage 3b would be GB61.3, BA00.Z (WHO, n. d.).
Concurrent
n the ICD -10-CM as well as ICD-11-MMS the term concurrent signifies the condition exists at the same time but is not responsible for the other diagnosis, e.g. your introduction into 2 or 3 main points, so it’s easy for your readers to follow. Each paragraph or two should focus on one point.
Closing -Don't mix up history of and current, acute, chronic, causal, concurrent
Let's not add injury to insult by mixing up an existing condition with one that is healed or in remission. Surviving cancer is already a challenge for many!
Resource:
2023 ICD-10. CM. (n. d.). Retrieved December 15, 2022, from https://www.cms.gov/medicare/icd-10/2023-icd-10-cm
World Health Organization. (n. d.). World Health Organization. Retrieved December 15, 2022, from https://icd.who.int
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