Personal and Family History ICD-10-CM codes

History codes are secondary codes that explain why a patient is being screened, monitored, or treated differently. Family history (Z80 to Z84) is reported when a relative's disease places the patient at higher risk: Z80.0 digestive cancer, Z80.3 breast cancer, Z80.41 ovarian cancer, Z80.42 prostate cancer, Z81.x mental and substance disorders, Z82.3 stroke, Z82.49 ischemic heart disease, Z82.5 asthma, Z82.62 osteoporosis, Z83.3 diabetes, Z83.42 familial hypercholesterolemia, Z83.511 glaucoma, Z83.71x colon polyps (subdivided in FY2025 by polyp type), Z84.81 carrier of a genetic disease, Z84.82 sudden infant death syndrome. The relative and the condition must be documented; a generic family history of cancer is Z80.9 only when no site is recorded.

Personal history (Z86, Z87) is for a condition that no longer exists and is not receiving treatment but affects current care. Frequently reported examples: Z87.891 (history of nicotine dependence, the most used code in the range), Z86.73 (TIA or stroke without residual deficits), Z86.718 (DVT) and Z86.711 (pulmonary embolism), Z86.16 (COVID-19), Z86.14 (MRSA), Z86.32 (gestational diabetes), Z86.0101 (adenomatous colon polyps), Z87.440 (recurrent UTI), Z87.81 (healed fracture), Z87.820 (traumatic brain injury), and Z87.892 (anaphylaxis). Personal history of malignancy has its own category, Z85, covered in a separate guide.

The history code is wrong when the condition is still present. A patient who had a stroke and still has hemiparesis is coded I69.35x, not Z86.73; a patient with atrial fibrillation on anticoagulation is I48.x, not Z86.79; a patient with asthma that is quiet today still has asthma. Similarly, Z87.891 requires the patient to have quit; a current smoker is F17.2x. Coders cannot infer a history from a medication list or a problem list that lacks a status; documentation should say resolved, history of, or status post.

History codes may be first-listed only when they are the reason for the visit and no screening or follow-up code applies, which is unusual. The usual pattern is a screening or follow-up code first (Z12.11, Z08, Z09) with the history code second, or a problem code first with the history code adding risk context. Z80 to Z84 and Z86 to Z87 are all accepted as secondary diagnoses on any claim and are often what turns a denied screening into a covered high-risk screening.