Before our discussion of the term past medical history (PMH), let’s briefly reflect on the risk adjusted payment paradigm, or MRA as it’s known in Medicare Advantage circles. CMS bases the bulk of the capitation payment made to MA plans on the health status of the patient, as reflected by the conditions reported by a healthcare provider. CMS guidelines state that the ICD-10-CM codes for these diagnoses are reported in a face-to-face encounter with an authorized provider who has “monitored, evaluated or treated” them. This means that payment is not warranted because the patient merely has a medical condition that prompts a risk-adjusted payment, but because the provider did something about the condition (e.g., monitored, evaluated or treated).

PMH is generally defined as a medical condition the patient had, with emphasis on the past part of the phrase. Logically, one would believe that a diagnosis in the PMH is resolved but perhaps for surveillance or other reasons, the provider wants to preserve its history by mentioning it in a section of the chart and visit note. However, some clinicians focus on the history part of the PMH title and use that section of the chart/note to document conditions the patient has, as in the patient has a history of leg amputation or heart failure. So, is a PMH condition active or resolved? Good question, and one around which some recent events have prompted this discussion.

Some PMH conditions are resolved after a period of time. Examples include injuries, like fractures; acute events, such as strokes, heart attacks and bowel obstructions; and of course, COVID-19. If these issues recur, they are coded again at that time. For providers who tend to call every condition a “history of,” the water gets murkier. If the condition is one that lasts for a lifetime – such as heart failure, which stabilizes or decompensates, but is never cured – it is coded when the provider “monitors, evaluates or treats” it. However, there is a school of coding thought that believes these lifetime conditions can be coded from the PMH section of the note, whether the clinician addressed them at the visit or not, and use examples like ostomies and amputations in their debate. Granted, amputations are lifetime conditions, but the note must contain information that brings it into the visit, as when the provider mentions it in the physical exam. Ostomies are not so clear-cut as they are sometimes reversed; but here too, the examination should include even the most basic documentation about the ostomy.

We believe the main confusion about PMH coding goes back to another CMS guideline that states you report conditions that are assessed at the visit and also those that “impact the evaluation and management” of other conditions. So, for example, if the patient is diabetic and the provider considers this condition when planning the treatment of another diagnosis, he or she can code for the diabetes and document this consideration, which impacts medical decision-making and the E/M code. However, this does not mean the coder can simply pluck the condition out of the PMH section and submit the code. There must be documentation on the visit note of the provider’s consideration of that lifetime condition when planning other treatment.

We want our clients to be mindful of the different ways PMH may be used and to be vigilant against anyone submitting codes “because the conditions were listed in the past medical history,” as we were recently told by a healthcare professional. Medical coding is not a black and white world; there is much gray and context, which affect code selection and reporting. The best compliance-oriented approach is to establish a system where all risk adjusted conditions are evaluated and submitted to the plan during each reporting period.

One last point: make sure your PMHs contain only valid conditions. We can’t tell you the situations we’ve seen where erroneous diagnoses that were subsequently removed, remain in the PMH, or a condition was added by a specialist simply to order a test, the result of which was negative, making the condition invalid for the patient. Payors will retroactively remove conditions, for which entities were paid, and which were later found to be unsupported; keep in mind that the CMS look-back period is six years. Make sure you know what risk adjusted codes are being submitted on your members’ behalf because whether you reported them or someone else did, the payment adjustment will affect your finances.