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Spot Common Documentation Deficiencies in Specific Code Categories

    Assigning accurate medical codes involves having substantial documentation sources and meeting specific requirements based on the type of code. Certain code categories present unique documentation challenges that need to be addressed to support code assignments.

    Incomplete documentation with missing key information can lead to a chain of issues and problems. Beyond knowing the foundations of accurate coding, it would make a big difference to be aware of challenges within specific code categories and their requirements for accuracy.

    Keep an eye out for common documentation deficiencies in these specific code categories:


    • Inconsistent provider documentation, such as conflicting information regarding the location, laterality, or cause of the wound.
    • Clinical documentation that doesn’t provide enough information to assign an accurate wound code
    • Difficulty locating wound records consistently within the medical record
    • Discrepancies between the severity of the wound and the skilled services and resources provided
    • Lack of documentation supporting delays in healing and the need for ongoing treatment
    • Failure to document the patient’s response to treatment, treatment outcomes, and any changes made to the treatment plan

    Sequela of Cerebral Injury

    • Failure to connect residuals to the CVA in the provider’s documentation
    • Making assumptions about the connection between symptoms and a prior CVA without physician confirmation
    • Failure to identify the underlying cause of the cerebral injury and distinguish between traumatic and non-traumatic injuries
    • Documentation of residuals from a Transient Ischemic Attack (TIA), which cannot be coded due to the transient nature of TIAs, requiring clarification from the provider through queries


    • Provider must document the relationship between the condition and the care or procedure provided
    • Unclear documentation regarding the cause-and-effect relationship between two conditions may require querying the provider for clarification
    • Making assumptions about the relationship between two conditions without provider confirmation can lead to inaccurate coding and billing


    • Provider does not include specifics and detail needed for accurate code assignment
    • Failure to document the primary site and laterality of metastatic tumors can result in inaccurate code assignment
    • Using unspecified laterality for neoplasms is not sufficient as a primary diagnosis
    • Lack of clarity regarding the status of a malignancy (resolved, in remission, or relapsed) can lead to inaccurate code assignment
    • Making assumptions about the status of malignancy based on long-term maintenance treatments can result in inaccurate coding and billing
    • Clear documentation regarding masses or tumors is essential to assign accurate codes. Providers should be queried for additional details regarding the etiology of masses or tumors, as the terms “mass” and “tumor” do not lead to interchangeable code categories.

    Mental Disorders

    • Lack of identification of underlying etiology when coding vascular dementia
    • Conflicting documentation of the type of dementia and inconsistent documentation throughout the medical record
    • Failure to use the “with” convention and connect comorbid conditions to mental disorders according to ICD-10-CM classification
    • Failure to confirm the presence of an unlisted mental/behavioral disorder indicated in the record through queries
    • Failure to code a mental/behavioral disorder that could impact the patient’s plan of care and outcomes

    Neuro Disorders

    • Failure of provider to specify “chronic pain syndrome” in documentation
    • Use of vague terms like “chronic pain” or “generalized pain” without specifying the underlying condition or cause, which can lead to inaccurate code assignment for central pain syndrome or chronic pain syndrome
    • Failure to query the provider when there is no cause or source listed for pain and there is documentation that specifies chronic pain
    • Lack of understanding that Parkinson’s disease and parkinsonism are not interchangeable terms, leading to incorrect code assignment
    • Failure to ask the provider for clarification when there is conflicting documentation regarding the type of disorder the patient has

    Social Determinants of Health (SDOH)

    • Failure to assign codes for SDOH, which can impact the patient’s overall health and outcomes
    • Failure to assess and document SDOH, including literacy level, occupational risk factor exposure, housing and economic circumstances, and problems related to the social environment
    • Mistaken belief that SDOH codes need to be provider-confirmed when they can be assigned based on clinician documentation

    The Importance of Coders’ Knowledge of Documentation Requirements

    Clinical documentation within a patient’s medical record is vital for validating eligibility for home health services, ensuring accurate ICD-10-CM coding, complying with regulations, and supporting reimbursement claims. Failure to meet the Centers for Medicare and Medicaid Services (CMS) guidelines and provide adequate documentation can compromise the quality of patient care, negatively impact reimbursement, and result in inaccurate data reporting. 

    Coders play a crucial role in ensuring the completeness and accuracy of clinical documentation. They need to go beyond simply extracting diagnosis codes from the F2F encounter documentation and supporting records. Coders should also know how to supplement code assignments and identify any gaps in the patient assessments. To achieve this, coders should actively work with other clinicians and the intake team to obtain more substantial documentation, which will support code assignments and optimize reimbursements.