Find comprehensive information on documenting a history of tuberculosis in healthcare settings. This resource covers clinical documentation requirements, medical coding guidelines for active TB, latent TB infection LTBI, and history of TB disease, ICD-10 codes (A15, A16, Z86.16), SNOMED CT concepts, and best practices for accurate and complete patient records. Learn about relevant diagnostic tests, treatment history documentation, and the importance of clear communication in medical records for patients with a history of pulmonary tuberculosis, extrapulmonary tuberculosis, or drug-resistant TB.
Also known as
Personal history of pulmonary TB
History of tuberculosis of the lung.
Personal hist of extrapulm TB
History of tuberculosis not in the lung.
Personal hist of other TB
History of tuberculosis, site unspecified.
Respiratory tuberculosis
Active tuberculosis infections of the respiratory system.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the TB currently active?
Yes
Do NOT code as history. Code the active TB based on site and type (e.g., A15-A19).
No
Is there evidence of past TB treatment?
When to use each related code
| Description |
|---|
| History of TB |
| Latent TB Infection |
| Sequelae of TB |
Coding confusion between latent (Z83.110, Z83.120) and active (A15-A19) TB based on incomplete documentation. Impacts quality metrics and reimbursement.
Using unspecified codes (e.g., Z83.1 without laterality) when more specific documentation is available. Reduces data accuracy for surveillance and research.
Incorrectly coding history of TB when the patient has current active disease or sequelae. Leads to inaccurate reporting and potential treatment errors.
Patient presents with a history of pulmonary tuberculosis (TB), confirmed by positive sputum culture for Mycobacterium tuberculosis in [Date of diagnosis]. Treatment was initiated with a standard four-drug regimen of isoniazid, rifampin, pyrazinamide, and ethambutol, and completed on [Date of treatment completion]. Patient reports adherence to the full course of therapy and denies any recurrent symptoms such as cough, hemoptysis, fever, night sweats, or weight loss. Current physical examination reveals clear lung fields with normal breath sounds. Latent tuberculosis infection, TB infection treatment, and Mycobacterium tuberculosis complex are considered in the context of past infection. The patient is advised to continue routine monitoring for potential reactivation, including symptom surveillance and periodic chest x-rays as clinically indicated. This history of tuberculosis is documented for accurate medical coding and billing purposes, including appropriate ICD-10 codes (A16.9, Z86.11) and relevant SNOMED CT concepts. This diagnosis impacts future healthcare decisions regarding infectious disease risk assessment and management.