Patient has a “history of…”

Nicoletti Notes July 2026
Published on July 23rd, 2026

Please see Dr. Oubre’s commentary at the end of this article.

At our June webinar, Dr. Robert Oubre was asked about the phrase in the HPI “patient has a history of…” Although Dr. Oubre was discussing “CDI and Coding for Arrhythmias” and the question of history of a-fib, it raised the wider issue. We wanted to know what he thought about the phrase and how to interpret it in a clinical note. (His webinar got rave reviews, and is one of a series of webinars he is doing on CDI and coding for cardiac conditions.) Dr. Oubre’s webinar

Those five words appear in many chart notes. But what do they mean?

Whether the condition is active, current and being managed or is truly a “personal history of” condition matters a lot in coding. It matters both for the level of E/M service being reported (is this a current problem being managed?) and diagnosis coding (does the diagnosis have a risk adjustment score?).

If the HPI says “history of hypertension” can the coder know if it is a today problem without a query to the practitioner? Often, yes. If the HPI goes on to note the patient is taking their BP medications with no side effects, is or isn’t taking their BP at home, and the A/P notes that the hypertension is “well controlled, continue lisinopril….,” then the coder can accurately determine that it is an active problem that was assessed and managed at the visit. Hypertension can be used in selecting a level of service and hypertension is an accurate diagnosis code.

What about an HPI in an internist’s note that says “history of breast cancer?” In the note, the HPI doesn’t discuss symptoms or treatment. The exam is normal. But, the physician moves the diagnosis code of breast cancer from the problem list to the assessment and plan. In that case, a coder or reviewer can’t be sure and would need to clarify with the physician. According to ICD-10-CM guidelines, only use a malignant neoplasm code if the patient has evidence of the cancer or is receiving treatment for the cancer. If neither of those are true, use a history of malignant neoplasm code. If neither of those or true, it would be incorrect to consider it a problem managed. And, this effects diagnosis coding for groups with risk-based contracts. Reporting that a patient has a malignant neoplasm when the there is no evidence of disease or treatment incorrectly raises the risk score.

The OIG has been auditing diagnosis coding for Medicare Advantage Organizations. Among other conditions, they reviewed stroke, MI, and malignant neoplasm of the breast, colon, lung and prostate. They found many encounters incorrectly coded with the active condition when it should have been history of. Here is a chart that I use to show the difference.

• Active/current condition: use the condition’s ICD-10-CM code (e.g., E11.9 for Type 2 diabetes mellitus without complications), reported when the condition is being monitored and treated or when it affects the care provided during the encounter.
• Personal history: use a code from the Z85–Z87 range, used when the condition is resolved, requires no active treatment, and does not affect ongoing management.

In some cases, the coder’s understanding of coding rules can make it easy to differentiate. If the note says, “Patient is here for follow up of a stroke. Was admitted last week…” the coder will know that the patient is not currently having a stroke. If the note is clear that the patient is free from cancer and isn’t receiving treatment, the coder will know it is personal history of malignant neoplasm. If the patient has a history of hypertension noted in the HPI and that condition is assessed and managed, it is a current condition. But, if the documentation isn’t clear, coders will need to clarify with the practitioner. The most important thing to keep in mind is that “patient has a history of…” can mean different things to the practitioner and the coder.

I asked Dr. Oubre to comment and he generously did:

The habitual use of “history of” is one of the more frustrating problems in clinical documentation. It’s really a habit that has been carried forward for over a century, back when most medical conditions were thought of as acute rather than chronic. Patients had a history of measles or a history of yellow fever because they recovered from those illnesses.

Today, though, most of our patients live with chronic conditions like hypertension, diabetes, heart failure, and COPD. Ideally, physicians would naturally write something like, “This is a 72 year old male with COPD, hypertension, and diabetes…” instead of “history of COPD, hypertension, and diabetes.” Unfortunately, that old habit has persisted.

The phrase “history of” is inherently confusing. It’s like me saying I have a “history of eating too much candy.” But…I still do. The phrase doesn’t really tell you whether something is past or present.

For those of us in the coding world, we know exactly why this matters. If the documentation doesn’t otherwise make it clear that the condition is active, we either can’t code it or we have to send a query for clarification, neither of which is ideal. Even worse, if we do code it despite unclear documentation, payers can, and do, issue denials based on that ambiguity alone. I fought one of those just last week.

I’ve had some success getting a handful of physicians at my institution to change their documentation habits, but it’s definitely an uphill battle. It’s even harder when IT teams, including physician CMIOs, continue rolling out HPI templates that automatically populate “past medical history” language into notes. Those templates reinforce the very habit we’re trying to break.

I wish I had a magic bullet, but changing long standing documentation habits and changing templates are both difficult. Good luck out there!