History Codes (Z80–Z87): When Is a Condition “History Of” Rather Than Current?

“There are two types of history Z codes, personal and family. Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring. Family history codes are for use when a patient has a family member(s) who has had a particular disease that causes the patient to be at higher risk of also contracting the disease.”

Charts use “history of” for anything in the past — including conditions still being treated. The classification uses it only for conditions that are over. The active-cancer guide linked below is the largest single case of that boundary; the same test applies to every history code.

• Guidelines I.C.21.c.4 — the definitions above; “Personal history codes may be used in conjunction with follow-up codes and family history codes may be used in conjunction with screening codes to explain the need for a test or procedure. History codes are also acceptable on any medical record regardless of the reason for visit”; “The reason for the encounter (for example, screening or counseling) should be sequenced first and the appropriate personal and/or family history code(s) should be assigned as additional diagnos(es).” The history categories are listed there: Z80–Z84 family, Z85–Z87 personal, Z91.4-, Z91.5-, Z91.81, Z91.82, Z91.85 and others.
• Tabular — Z85 carries Code First for Z08; Z86 and Z87 carry Code First for Z09; Z86.73 (stroke without residual deficits) carries an Excludes1 for I69.- sequelae; Z87.891 excludes current nicotine dependence (F17.2-).
• Guidelines I.C.21.c.3 — the distinction from status: “A status code is distinct from a history code. The history code indicates that the patient no longer has the condition.”

1. Confirm the condition no longer exists and is not being treated. Still present or under treatment → the condition’s own code; residual deficit → the sequela code; a device or organ present → a status code.
2. Choose personal (Z85–Z87, Z91.-) or family (Z80–Z84).
3. Sequence the reason for the encounter first — screening, counseling, follow-up — and the history code as an additional diagnosis.
4. Follow the Code First notes: Z08 before Z85; Z09 before Z86/Z87, at a follow-up visit after completed treatment.
5. Read the code’s exclusions: I69 for a stroke with residuals; F17.2- for current tobacco dependence; Z86.00-/.01- for carcinoma in situ or benign neoplasm history rather than Z85.

1. Documentation: surveillance visit after completed breast cancer treatment, no evidence of disease. Result: Z08 → Z85.3. Why: Z85’s Code First note; the three-part active-vs-history test is met.
2. Documentation: prior stroke; the note says “no residual deficits.” Result: Z86.73. Why: its inclusion term names stroke without residual deficits; a residual would instead be an I69 sequela code, which Z86.73 excludes.
3. Documentation: “former smoker,” quit years ago. Result: Z87.891. Why: a documented current dependence would be F17.2-, which Z87.891 excludes.
4. Documentation: screening colonoscopy; father had colon cancer. Result: the Z12.1- screening code first, then the Z80.0 family-history code. Why: the reason for the encounter leads; family history explains the need for the test.

• A history code for a condition still under treatment (the active-cancer trap).
• Z86.73 for a stroke with residual deficits — I69.-.
• The history code sequenced before the follow-up or screening code.
• Z87.891 for a current smoker.
• A status code and a history code confused — a device present is status; a condition gone is history.

• Whether the condition is resolved and untreated, still active, or has left a residual.
• The reason for the encounter, which leads.
• Family history that explains a screening or counseling visit.
• For neoplasms: excised/eradicated, no further treatment, no evidence of disease.