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Documentation Counts

Using accurate diagnoses codes with supporting documentation provides a comprehensive assessment of a patient’s health status during encounters. These are some things to consider when choosing and documenting diagnosis codes:


Accurately represent the severity of a patient’s condition with specificity in diagnosis coding.

Example: Reporting type II diabetes mellitus without complications (E11.9) for a patient diagnosed with type II diabetes mellitus with diabetic nephropathy (E11.21).

Causal Relationship

Provide better details of patients’ service needs with documentation worded to show a linked relationship between conditions and manifestation. Try using words like “with,” “due to,” and “associated with.”

Example: Reporting hemiplegia (I69.059) due to CVA that occurred 3 months ago for a patient receiving physical therapy services.

Sequelae (Late Effects)

ICD-10 gives you the opportunity to report residual conditions that occur after an acute phase of an illness is over. Use sequelae codes (previously known as late effects) to give a more accurate description of a patient’s health status.

Example: Reporting hemiplegia following non-traumatic subarachnoid hemorrhage, affecting right dominant side (I69.051), instead of unspecified hemiplegia, affecting right dominate side (G81.91).

Status Codes

Status codes are both informative and can affect the course of treatment and outcomes. We depend on the help of our provider partners to document and report the following, when applicable to a patient, in a face-to-face encounter at least once each calendar year:

  • Amputations (Z89.0-Z89.9)
  • Ostomies (Z93.0-Z93.9)
  • Dialysis status (Z99.2)
  • Respirator dependence (Z99.11)
  • Alcohol dependence in remission (F10.21)
  • Drug dependence (F19.20)

Active vs. History of Cancer

Active cancer codes (C00-D49) support a present malignancy or one previously excised, yet treatment is ongoing through adjuvant therapy, like Lupron for prostate cancer.

Active cancer documentation should state:

  • Active cancer, receiving ongoing treatment
  • Active cancer, patient declines treatment
  • No evidence of active cancer and receiving adjuvant therapy

Personal history of cancer codes (Z85.00-Z85.89) support that a patient’s malignancy no longer exists. This code series also supports that a patient is not receiving active or adjuvant treatment, but that the cancer has the potential for recurrence and requires continued monitoring and surveillance.


To create an accurate reflection of conditions in documentation, certain elements are required in order to support the diagnosis codes. Auditors from CMS and other governing entities use the acronym M.E.A.T. while looking for correct diagnosis code selection and reporting on encounters.

These elements include:

  • Monitor – Signs, symptoms, disease progression
  • Evaluate – Medications, test results
  • Assess/Address – Counseling, review of records
  • Treat – Medications, therapy

Conditions only listed on a patient’s problem list without associated M.E.A.T. do not meet the requirements for accurate coding and documentation, causing a misrepresentation of the patient’s condition, which keeps us all further away from meeting our goal of being audit proof.


2017, Optum 360 ICD-10-CM Expert for Physicians
2014, AAPC Risk Adjustment Predictive Modeling, Documentation, and Capture of Diagnosis Codes