CMS Tips: Provider Minute: The Importance of Proper Documentation (Video)

Uploaded March 2020

HCC Coding, Risk Adjustment, and Physician Income

The Source ICD-10 Special Edition

ICD-10 Codes Tobacco/Nicotine Dependence, and Secondhand Smoke Exposure

Rheumatoid Arthritis ICD-10-CM Diagnosis Codes

Documentation and Coding Tips : Social Determinants of Health

Addressing the social determinants of health begins with identifying a patient’s needs and measuring their impact. Access this document for guidance on proper coding, and helpful resources:

Documentation and Coding: Functional Quadriplegia

This tip sheet offers guidance on how to submit diagnosis codes for Functional Quadriplegia, which is defined as “the inability to move due to severe disability or frailty caused by another condition without physical injury or damage to the brain or spinal cord.”

Documentation and Coding: Morbid Obesity

To accurately code a patient as morbidly obese, the provider must document the patient’s obesity in the medical record. Per 2020 ICD-10-CM Guidelines, “BMI codes should only be assigned when there is an associated, reportable diagnosis (such as morbid obesity). Do not assign BMI codes during pregnancy.”

Documentation and Coding: Risk Adjustment

This tip sheet offers guidance on proper risk adjustment coding. Risk adjustment relies on correct ICD-10-CM diagnosis coding to represent the member’s health status and to establish an accurate risk score.

Documentation and Coding: Protein-Calorie Malnutrition (PCM) or Protein-Energy Malnutrition (PEM)

To accurately code a patient as Protein-Calorie Malnutrition or Protein-Energy Malnutrition, the coder must document the diagnosis. Severity ranges from subclinical deficiencies to obvious wasting (with edema, hair loss, and skin atrophy) to starvation. Multiple organs are often impaired.

1765 20 Documentation and Coding Guide Anemia v5 FINAL

This tip sheet will offer guidance on how to submit diagnosis codes with greater specificity for coding Anemia Associated with Malignancy, Chemotherapy, or Immunotherapy. Created February 2021.