The documentation in the patient’s chart, conducted by both the provider and the clinician, is the foundation of the medical record. It tells the patient’s healthcare journey – it validates the patient’s eligibility for services, justifies that ICD-10-CM coding is accurate, demonstrates an agency has followed all regulations for providing patient care, and supports the agency’s claim for reimbursement. Clinical documentation that does not meet CMS guidelines and support the need for home health services has the potential to negatively impact the quality of patient care, reimbursement and data reporting for conditions and diseases.

Accurate code assignment requires professional responsibility to ensure code assignment comes from the proper documentation sources. There are specifics necessary to support the assignment of specific codes on the claim. Often, certain codes present unique challenges when present, or more importantly, when supporting information within the clinical documentation is not present. Reviewing the basics needed in provider documentation can greatly help with assigning codes accurately and compliantly:

  • All diagnoses must be stated or confirmed by the physician or a qualified provider
  • Never assign diagnoses if stated by provider with nebulous terms, such as “likely,” “suspected” or “consistent with”
  • Keep in mind that diagnoses cannot be assigned from lab reports or imaging without a physician’s interpretation of those results confirming the diagnosis
  • Many parts of the medical record can provide insight into code assignment or provide reasons for needed provider queries. Some forms of documentation that can support information related to code assignment include the history and physical (H&P), discharge summaries, operative reports, labs and imaging with interpretation and progress notes.

If there is missing information when assigning codes, a problem can occur with assignment. Look out for these common challenges within specific code categories:


  • Provider documentation that contains conflicting statements such as wound location, laterality or etiology
  • Clinical documentation that does not supports wound code assignment
  • Wound records that are not consistently found in the same place in the medical record
  • Skilled services and resources provided are not consistent with the severity of the wound
  • Wound documentation not supporting delays in healing and the need for continued treatment
  • Documentation does not include patient’s response to treatment, outcomes and treatment changes

Sequela of cerebral injury

  • Provider’s documentation not linking residuals to the CVA
  • Making assumptions that symptoms and prior CVA connected without physician confirmation
  • Not identifying the underlying etiology of the cerebral injury and whether it is traumatic or non-traumatic in nature
  • Documentation of residuals from a Transient Ischemic Attack (TIA), due to the transient nature of TIAs there are no codes for TIA residuals. In such cases the provider will need to be queried for clarification of the diagnosis.


  • Provider must document the relationship between the condition and the care or procedure
  • Documentation not clear related to the cause-and-effect relationship between two conditions, the provider will need to be queried
  • Making assumptions that two conditions are related. This connection can only be confirmed by the provider


  • Provider does not include specifics and detail needed for accurate code assignment
  • No documentation of primary site when metastasis is present. Laterality is needed also for accurate code assignment
  • Unspecified neoplasm laterality will not be a valid primary diagnosis
  • Documentation not clear as to whether the malignancy is resolved, in remission, or relapsed
  • Making assumptions based on long term maintenance treatments that neoplasms or malignancies are either active or resolved
  • Ensure documentation surrounding a mass or a tumor is clear enough to lead you to a payable code. The terms “mass” and “tumor” are not interchangeable and lead to different code categories, query the provider for further details related to the etiology of a mass or tumor.

Mental disorders

  • Underlying etiology is needed when coding Vascular dementia
  • No clarification for conflicting documentation of the type of dementia
  • Inconsistency with the type of dementia throughout the documentation
  • Don’t forget the “with” convention and when comorbid conditions can be connected to the mental disorder by the ICD-10-CM classification
  • Not making a query to confirm the presence of an unlisted mental/behavioral disorder when there are indications in the record (med list, documentation of symptoms, etc)
  • Not coding mental/behavioral disorder that has the potential to impact the plan of care and outcomes for the patient

Neuro Disorders

  • No provider specification of “chronic pain syndrome”
  • Using terms like “chronic pain” and “generalized pain” are not sufficient for assigning codes for central pain syndrome or chronic pain syndrome
  • No query when there is no cause or source listed for pain and there is documentation that specifies chronic pain
  • Not understanding that Parkinson disease and parkinsonism are not interchangeable terms
  • No query for conflicting documentation from the provider regarding the type of disorder the patient has

Social Determinants of Health (SDOH)

  • No code assignment of SDOH
  • Literacy level, occupational risk factor exposure, housing and economic circumstances, and problems related to social environment are not included in patient assessment
  • Making mistake that SDOH need to be provider confirmed, these can be assigned based on clinician documentation

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