Find information on documenting and coding a personal history of pulmonary embolism. This resource covers clinical documentation requirements, ICD-10 code Z86.711 for personal history of pulmonary embolism, best practices for healthcare providers, and tips for accurate medical coding. Learn about diagnosis documentation, past medical history, and appropriate terminology for a patient with a history of PE. Improve your understanding of pulmonary embolism diagnosis coding and documentation guidelines.
Also known as
Personal history of pulmonary embolism
Indicates a past episode of pulmonary embolism.
Pulmonary embolism
Covers current pulmonary embolism diagnoses, not history.
Personal history of other venous embolism
Relates to past venous embolisms, possibly including pulmonary.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the pulmonary embolism currently active?
Yes
Do NOT code as history. Code the acute pulmonary embolism (I26.-)
No
Is there any residual effect?
When to use each related code
Description |
---|
Prior pulmonary embolism |
Family history of PE |
Personal history of DVT |
Using unspecified codes (e.g., Z86.79) when more specific personal history codes (e.g., Z86.711) are applicable, impacting risk adjustment.
Lack of proper documentation to support the diagnosis, leading to potential coding errors and denials. CDI review needed for accuracy.
Incorrectly coding active pulmonary embolism (I26.9) instead of personal history, affecting quality reporting and reimbursement.
Patient presents with a personal history of pulmonary embolism (PE). The initial diagnosis of PE was made on [Date of original diagnosis] and was confirmed by [Diagnostic method used, e.g., CT pulmonary angiography, ventilation-perfusion scan]. The patient's prior pulmonary embolism risk factors included [List risk factors, e.g., deep vein thrombosis, recent surgery, prolonged immobility, oral contraceptives, family history of thromboembolic disease, factor V Leiden mutation, malignancy]. The patient's prior PE symptoms included [List symptoms, e.g., sudden onset shortness of breath, chest pain, cough, hemoptysis]. The patient was previously treated with [Specify treatment, e.g., anticoagulation therapy with warfarin, rivaroxaban, apixaban, dabigatran; thrombolysis]. Duration of prior anticoagulation therapy was [Duration]. The patient's current symptoms related to their history of PE include [List current symptoms or indicate "none"]. Current medications include [List current medications]. Assessment of current PE risk factors includes [List current risk factors or indicate "none"]. Plan includes [Specify plan, e.g., continued surveillance, anticoagulation management, referral to hematology, further diagnostic testing if indicated]. Patient education provided regarding signs and symptoms of recurrent PE, importance of medication compliance, and follow-up appointments. This documented history of pulmonary embolism impacts current medical decision-making regarding [Specify impact, e.g., choice of anticoagulation, duration of therapy, need for prophylaxis in high-risk situations]. ICD-10 code Z86.711 (Personal history of pulmonary embolism) applies.