ICD-10 Coding for History of Syphilis(Z86.13)
Complete ICD-10-CM coding and documentation guide for History of Syphilis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Syphilis
Z86.1-Z86.19Primary Range
Personal history of certain other diseases
This range includes codes for personal history of infectious diseases, including syphilis.
Key Information: ICD-10 code for history of syphilis
Essential facts and insights about History of Syphilis
Primary ICD-10-CM Code for history of syphilis
Decision Criteria
clinical Criteria
- Patient has no current symptoms and has completed treatment for syphilis.
documentation Criteria
- Medical record includes treatment history and serologic test results.
Applicable To
- Resolved syphilis
- Treated syphilis with no current infection
Excludes
- Current syphilis infection (A50-A53)
Clinical Validation Requirements
- Documentation of completed treatment for syphilis
- Non-reactive or stable low titer serologic tests
- Absence of symptoms or clinical findings of active syphilis
Code-Specific Risks
- Misclassification as active syphilis if documentation is unclear
- Potential audit if supporting documentation is insufficient
Coding Notes
- Ensure documentation clearly states the syphilis is historical and resolved.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting History of Syphilis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z86.13.
Impact
Clinical: May lead to inappropriate treatment or follow-up., Regulatory: Non-compliance with ICD-10 coding guidelines., Financial: Potential for incorrect billing and reimbursement.
Mitigation Strategy
Ensure documentation specifies 'history of' when applicable, Include treatment and serologic history in the record
Impact
Reimbursement: Incorrect coding could lead to overpayment or audit issues., Compliance: Misclassification as an active infection could result in non-compliance with coding standards., Data Quality: Inaccurate data on patient history and current health status.
Mitigation Strategy
Use Z86.13 for resolved syphilis cases with no current infection.
Impact
Coding historical syphilis as active can lead to audits.
Mitigation Strategy
Ensure documentation clearly states the syphilis is historical and resolved.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for History of Syphilis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Syphilis
Use these documentation templates to ensure complete and accurate documentation for History of Syphilis. These templates include all required elements for proper coding and billing.
Routine follow-up for a patient with a history of syphilis
Specialty: Primary CareRequired Elements
- Initial diagnosis date
- Treatment regimen and completion
- Current serologic status
- Absence of symptoms
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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