When coding, what must be coded if personal or family history affects current care?

When personal or family history affects current care, it is essential to code these histories as additional codes. This is because both personal and family medical histories can provide important context for understanding the patient's current health status and the rationale behind the treatment decisions. These extra codes help convey the full clinical picture, allowing for better healthcare management and communication among providers.

For instance, if a patient has a history of a certain condition that may predispose them to current health concerns, documenting that history can impact treatment options, risk assessments, and preventive care measures. Similarly, family history can be critical in identifying hereditary conditions that may influence the patient’s health.

In contrast, focusing solely on the primary diagnosis or only including personal or family history in isolation does not capture the complete scope of factors that may be relevant to the patient’s care. Therefore, adding history codes provides a more comprehensive approach to coding and enhances the clarity and completeness of the patient's medical record.