‘Personal History Of’

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‘Personal History Of’ is defined as a past condition that no longer exists, is not receiving active treatment, but may require monitoring due to recurrence risk, according to ICD-10-CM (CDC/WHO).

Why does this matter? Although the concept seems straightforward, confusion persists among both providers and medical coders regarding when to document a condition as ‘personal history of’ versus when it should be coded as an active condition.

Let’s clarify the distinction.

Conditions Commonly Mis‑Coded as Active (But Should Be ‘Personal History Of’)

  1. Myocardial Infarction (MI)
  • Active MI = ≤28 days; after that → I25.2 old MI = personal history.
  1. Ischemic Stroke / CVA
  • If no residual deficits → Z86.73 (personal history of TIA & cerebral infarction).
  1. Deep Vein Thrombosis / Pulmonary Embolism
  • If resolved but patient on prophylactic anticoagulation → history of DVT/PE (Z86.71‑).
  1. Cancer (solid tumors)
  • When no longer in active treatment (chemo, radiation, surgery) and no active disease → Z85.x personal history of malignant neoplasm.
  1. Surgically resolved conditions

Examples: appendectomy, cholecystectomy, post‑repair aneurysm, bowel resection when condition resolved → history code.

  1. Resolved infections
  • Pneumonia or sepsis treated and resolved → no longer coded as active

Conditions Commonly Mis‑Coded as “Personal History” (But Should Be Active)

Chronic diseases (still present or monitored)                                                            —-CHF, COPD, diabetes, CKD, cirrhosis, dementia—never coded as history unless cured.

Conditions with residual deficits                                                                          Post‑stroke hemiparesis → code I69.x, not “history of CVA.

Active wound care or unresolved postoperative conditions                                       If still receiving active treatment (e.g., antibiotics), condition remains active.

Compliance Concerns

Major compliance risks arise when documentation fails to distinguish accurately between active conditions and those that should be coded as a personal history. Incorrectly coding resolved conditions as active can inflate risk scores and create exposure for fraud‑related findings, while using history codes for conditions that remain active results in lost HCC capture and undermines revenue integrity.

Risk adjustment also requires clear MEAT-supported documentation; when a condition does not demonstrate monitoring, evaluation, assessment, or treatment, it must be coded as a history condition.

Additionally, unclear placement of “history of” within the HPI can lead coders to misinterpret a resolved condition as active, increasing the likelihood of CDI queries, billing delays, and denials. These issues collectively heighten audit vulnerability, as OIG, CMS, and Medicare Advantage auditors routinely target encounters where active diagnoses are insufficiently supported.

Summary

‘Personal history of’ should only be used when the condition is fully resolved, not under active treatment, and not currently affecting care except for recurrence (surveillance) monitoring. Misuse has significant HCC, CDI, and audit implications.

Correct code assignment depends on MEAT, clinical status, and ICD‑10‑CM rules. The conditions most commonly miscoded include MI, CVA, cancer, and DVT/PE. Chronic conditions (CHF, COPD, CKD, diabetes) should almost never be coded as history.

Resources

2026 ICD-10-CM Official Guidelines

Innovative Health Alliance: Active vs. History

CMS: ICD-10-CM 2026 Files