Risk Adjustment is the method developed and used by the Department of Health and Human Services (HHS) to predict health costs of members enrolling in Affordable Care Act (ACA) or Medicare Advantage (MA) plans. Risk Adjustment prevents health plans from only attracting and enrolling healthy members, known as adverse selection. Effective Risk Adjustment programs ensures members are receiving quality care and enable health plans to offer more comprehensive and affordable benefits to members.
Arkansas Health and Wellness is required by law to report complete and accurate diagnostic information on enrollees. This information is gathered from claims data and information obtained from medical record reviews and audits.
We encourage all providers to take every face-to-face encounter as an opportunity to provide comprehensive care and document chronic and co-existing conditions, active status conditions, and pertinent past conditions using the applicable ICD-10 code and supporting the condition with proper documentation in the medical record.
Arkansas Health and Wellness is required to validate member diagnosis annually through a Risk Adjustment Data Validation (RADV) audit. Health plans also engage in chart review projects to ensure member diagnoses are being reported accurately.
Arkansas Health and Wellness engages providers through various incentive programs that reward providers for risk adjustment gap closure.
An arrhythmia is an abnormal heart rhythm. Arrhythmias occur when the electrical impulses that coordinate your heartbeats don’t work properly, causing your heart to beat too fast, too slow or irregularly.
- Heart attack
- Abnormal heart valve
- Coronary artery disease
- Emphysema /lung disease
- Congenital defects
- Viral infections
- Metabolic imbalance
- Thyroid disorder
- Chest pain
- Weakness / fatigue
- Blood pressure change
- Shortness of breath
- No symptoms
Tachycardia is a fast heart rate; in adults a rate greater than 100 beats per minute is considered tachycardia. Paroxysmal tachycardia is characterized by periods of rapid heartbeats that start and stop abruptly.
There are 2 types of paroxysmal tachycardia:
- Supraventricular Tachycardia occurs when the rapid heart rate originates in the heart’s upper chambers (the atria)
- Ventricular Tachycardia involves a rapid heart rate originating in the lower chambers of the heart (the ventricles). Ventricular tachycardia lasting longer that a few seconds can lead to ventricular fibrillation, the most serious and life-threatening cardiac rhythm disturbance.
Atrial Fibrillation and Flutter
Atrial fibrillation and flutter are arrhythmias involving the atria. They may come and go or be sustained. Risk of stroke or heart failure is increased if either atrial fibrillation or atrial flutter is not controlled or persists for more than a couple of days.
- Atrial fibrillation is a rapid, irregular heart rate caused by chaotic electrical impulses in the atria. These cause rapid, uncoordinated, weak contractions of the atria and blood is not moved from the atria into the ventricles effectively. Atrial fibrillation is the most common type of arrhythmia.
- Atrial flutter is characterized by a rapid, but regular heartbeat that causes the atria to beat too fast, producing atrial muscle contractions that are faster than and out of sync with the ventricles.
Sick Sinus Syndrome (SSS)
SSS, also known as "Sinoatrial node dysfunction" or "Tachycardia-Bradycardia syndrome," is the name given to a group of arrhythmias in which the sinus node, the heart’s natural pacemaker, doesn’t send impulses properly. As a result, the heart might beat too fast, too slow, or it might speed up and slow down intermittently.
Treatment options depend largely upon the severity of a patient’s symptoms. Many with SSS initially experience few, if any, symptoms. At this stage treatment usually consists of regular checkups and monitoring. Once a patient’s symptoms become more problematic, further treatment is pursued.
Many with SSS eventually need a permanent artificial pacemaker to monitor and regulate the heart’s rhythm and send electrical signals to stimulate the heart when it’s beating too slowly.
A pacemaker controls but does not cure SSS, therefore, it is a reportable chronic condition.
Patients who have a rapid heart rate as part of their SSS may need additional treatments after pacemaker placement to control fast rhythms.
- Anti-arrhythmic drugs
- Heart-rate control drugs
- Anticoagulant therapy
- Electrical cardio conversion
- Anti-bradycardia pacing
- Coronary artery bypass
- Pulmonary vein isolation
- Catheter ablation
- Maze procedure
- Valve surgery
There are many cardiac devices designed to help control irregular heartbeats, such as pacemakers, implantable cardioverter-defibrillators (ICDs) and loop recorders. These are often surgically implanted in the chest or abdominal wall, just below the collarbone.
Coding and Documentation
When documenting cardiac arrhythmias, include the following:
- Location — atrial, ventricular, supraventricular, etc.
- Rhythm name — flutter, fibrillation, etc.
- Acuity — paroxysmal, persistent, longstanding, chronic, etc.
- Cause — hyperkalemia, hypertension, etc.
- Documentation must state the relationship between anticoagulation therapy and cardiac arrhythmias. It cannot be assumed since anticoagulants are used to manage other conditions.
- Even when the conditions are linked, document the type, status, and severity of the arrhythmia. Anticoagulant therapy is also used to prevent blood clots in patients with a history of cardiac arrhythmias. - Z79.01: Long term (current) use of anticoagulants
- Document “history of,” along with a specification that the condition is no longer current in the final assessment.
- If the condition is currently active and under management do not specify as “history of,” even if stable.
- There is not a specific code for personal history of cardiac arrhythmia. Use Z86.79: Personal history of other diseases of the circulatory system.
PRESENCE OF CARDIAC DEVICE
- Z95.0 Presence of a cardiac pacemaker
- Z95.810 Presence of automatic (implantable) cardiac defibrillator
- Z95.811 Presence of heart assist device
- Z95.818 Presence of other cardiac implants and grafts
 AHA Coding Clinic, 2019 Q1, Volume 6 pg. 3
AMB21-AR-H-112 Updated October 22, 2021
Chronic Kidney Disease
The clinical criteria for chronic kidney disease (CKD) is either kidney damage or a decreased glomerular filtration rate (GFR) of less than 60 for at least three months. When the reduction of functional renal mass reaches a certain point, irreversible sclerosis leads to a progressive decline in the GFR.
ICD-10-CM classifies CKD by the severity level of decreased kidney function.
Mild kidney damage (normal function)
Mildly decreased renal function
Mild to Moderate
Moderate to Severe
Renal disease, renal insufficiency, or renal failure NOS.
The GFR value may can be used as supporting evidence for renal failure, renal insufficiency, or other renal diseases documented by the provider. It cannot be interpreted to stage CKD or other renal condition.
Signs and Symptoms
Patients with CKD stages 1-3 are generally asymptomatic. Typically, it is not until stages 4 or 5 that endocrine/ metabolic derangements or disturbances in water or electrolyte balance become clinically manifested.
When the disease progresses, symptoms presented are:
- Edema of feet and ankles
- Need to urinate more often, especially at night
- Blood or protein in urine
- Chest pain
- Twitching and cramps in the muscles
- Shortness of breath
- Erectile dysfunction, amenorrhea, or decreased libido
- Platelet dysfunction with tendency to bleed
- Loss of appetite
- High blood pressure (hypertension)
Coding and Documentation
Acute vs. Chronic
Acute kidney failure is not an acute exacerbation of chronic kidney failure. They are two separate and distinct conditions. The causes, symptoms, treatments, and outcomes of acute and chronic are different.
- Acute renal failure has an abrupt onset and is potentially reversible.
- Chronic kidney failure progresses slowly over time and can lead to permanent kidney failure.
If both acute and chronic kidney failure are clearly documented, code both N179 (AKI) and N18.
End Stage Renal Disease
End-stage renal disease (ESRD) is when the kidneys permanently fail to work. ESRD requires renal dialysis or kidney transplant.
- Code N18.6 is assigned when ESRD is documented by provider
- Code Z99.2: Dependence on renal dialysis when documentation supports the presence of an arteriovenous shunt/fistula for dialysis
- Code Z91.15: Patient's noncompliance with renal dialysis when explicitly documented
Patients with CKD may also suffer from other serious conditions, most commonly diabetes mellitus and hypertension. The sequencing of the CKD code in relationship to codes for other contributing conditions is based on the conventions in the Tabular List.
Diabetes with Kidney Complications
Relationship between diabetes and CKD or ESRD (N18.1 - N18.6) is assumed when both conditions are found anywhere in the note as long as there is no conflicting documentation
- Use an additional code to identify stage of chronic kidney disease (N18.1-N18.6).
- The ICD-10 “With” guideline only applies to CKD.
- Unspecified (N18.9): When CKD unspecified has been assessed during the encounter.
Hypertensive Chronic Kidney Disease
Hypertension and CKD have an assumed relationship unless documentation specifies CKD is caused by a condition other than hypertension.
- Assign code from category I12
- Use an additional code to identify stage of chronic kidney disease with I12.0 (N18.1-N18.4, N18.9) or I12.9 (N18.5-N18.6)
Hyperparathyroidism is a pathologic manifestation of CKD.
- Documentation must link the complication and the conditions to assign code N25.81: Hyperparathyroidism of renal origin.
- Do not assume causal relationship between these two conditions.
 AHA Coding Clinic, Volume 27, Q3, 2010, Pg. 5
AMB21-AR-H-111 Updated October 22, 2021
Coagulation Defects and Other Specified Hematological Disorders
Coagulation (also known as clotting) is the process by which blood changes from a liquid to a gel, forming a blood clot. Clotting results in hemostasis, the cessation of blood loss from a damaged vessel. It is achieved through a series of interactions between platelets, blood vessel walls, and adhesive blood proteins known as clotting factors.
Coagulation disorders involve disruption of the clotting process and may result in:
- Hemorrhage: Too little clotting that causes an increased risk of bleeding. Examples include:
- Von Willebrand disease
- Primary thrombophilia
- Activated protein C resistance
- Hereditary factor XI deficiency
- Evans syndrome
- Allergic purpura
- Thrombosis: Too much clotting that causes blood clots to obstruct blood flow. Examples include:
- Factor V Leiden mutation
- Antithrombin III (ATIII) deficiency
- Primary thrombocytosis
- Antiphospholipid antibody syndrome
- Prothrombin (PT) gene mutation
- Protein C or protein S deficiency
- Lupus anticoagulant syndrome
Signs, Symptoms, and Treatment of Hemorrhagic Disorders
Signs & Symptoms
- Blood in the urine or stool
- Sudden pain, swelling, and warmth in the joints or muscles
- Nosebleeds that seem to have no cause
- Repeated vomiting
- A painful headache that will not go away
- Extreme fatigue
- Bruising easily and excessively, or petechiae
- An injury that will not stop bleeding
- Prolonged bleeding from cuts, surgery, or dental work
- Vision problems, such as double vision
- An enlarged spleen
- RICE — Rest, ice, compression, and elevation
- Desmopressin (Willebrand factor synthetic hormone)
- Discontinuation of aspirin and other NSAIDs
Hemophilia is a hereditary blood disease characterized by greatly prolonged coagulation time. The blood fails to clot, and abnormal bleeding occurs.
Hemophilia is a sex-linked hereditary trait transmitted by normal heterozygous females who carry the recessive gene occurring almost exclusively in males.
- Factor VIII deficiency (classic hemophilia, hemophilia A) associated with recurrent, spontaneous, and traumatic hemarthrosis
- Factor IX deficiency (hemophilia B, Christmas disease, plasma thromboplastin component)
- Von Willebrand disease
- Type 1 - Partial quantitative deficiency of von Willebrand factor; Type 1C von Willebrand disease
- Type 2 subtypes include qualitative defects of von Willebrand factor
- type 2A - with decreased platelet adhesion and selective deficiency of high-molecular-weight multimers
- type 2B - with high-molecular-weight von Willebrand factor loss; with hyper-adhesive forms; with increased affinity for platelet glycoprotein lb
- type 2M - with defective platelet adhesion with a normal size distribution of von Willebrand factor multimers
- type 2N - with defective von Willebrand factor to factor VIII binding; with markedly decreased affinity for factor VIII
- Type 3 - (Near) complete absence of von Willebrand factor; Total quantitative deficiency of von Willebrand factor
- Acquired von Willebrand syndrome
- Other – platelet-type; pseudo-von Willebrand disease
Acquired hemophilia, developing after birth, is a rare condition caused by the development of antibodies (immune system proteins) directed against the body’s own VIII or IX blood clotting factors.
- Non-genetic disorder affecting both males and females
- Can be related to other conditions (i.e., pregnancy, cancer, certain medications)
Frequency and severity of hemorrhagic activity induced by hemophilia are related to the amount of coagulation factor in the blood.
5% to 40% of normal coagulation factor
1% to 5% of coagulation factor activity
less than 1% of coagulation factor activity
complications only after having undergone surgery or major physical trauma
some spontaneous hemorrhage but normally exhibit bleeding provoked by trauma
spontaneous hemarthrosis and bleeding
Treatment depends on the severity of the disease and may include the administration of blood clotting factors such as Factor VIII, Factor IX, Factor VIIa and, Anti-inhibitors to control the bleeding.
Thrombocytopenia occurs when the platelet count falls lower than 150,000 platelets per μl of blood. Circulating platelets are reduced by one or more of the following:
- Trapping of platelets in spleen caused various other disorders
- Decreased platelet production can be caused by leukemia, chemotherapy, heavy alcohol consumption certain anemias, and viral infections (Hep B, HIV)
- Increased breakdown of platelets
- Identify and treat underlying cause
- Blood or platelet transfusions
Primary Thrombocytosis, also known as Primary Thrombocythemia (ET), is an uncommon disorder in which the body produces too many platelets.
Signs, Symptoms, and Complications
- Vision changes
- Increased risk of blood clots, myelogenous leukemia (AML), and myelfibrosis
- Low dose aspirin
- Interferon alfa or pegylated interferon alpha 2a
Coagulopathy is impaired clot formation or any derangement of hemostasis resulting in either excessive bleeding or clotting. Document coagulopathy when appropriate to reflect the seriousness of the condition. Specify the underlying etiology of coagulopathy to support the diagnosis.
- When patient is maintained on anti-platelets and/or an anti-coagulant, document coagulopathy due to anti-coagulation or anti-platelets use, if linked to bleeding.
- If coagulopathy is documented due to abnormal ROTEM (rotational thromboelastometry), additional clinical relevance will help validate the diagnosis:
- Screen in anticipation of blood products transfusion (ffp)
Coding & Documentation
Quality patient care relies on complete documentation.
- Accurately capture the patient’s health status.
- Note condition details, including status, complications, and comorbidities.
- Report the diagnosis to the highest specificity found in the documentation.
All providers must fully understand and follow all existing laws, regulations, and rules for hemophilia clotting factors and must properly submit valid claims for them. Relevant CMS manual instructions and policies may be found in the Internet-Only Manuals (IOMs) published on the CMS website.
ICD-10-CM Diagnosis Codes
Lists are not all-inclusive. Refer to the official ICD-10-CM diagnosis coding & documentation guidelines for the current year.
Anemia due to G6PD deficiency
Anemia due to other disorders of glutathione metabolism
Anemia due to disorders of glycolytic enzymes
Anemia due to disorders of nucleotide metabolism
Other anemias due to enzyme disorders
Anemia due to enzyme disorder, unspecified
Hereditary persistence of fetal hemoglobin [HPFH]
Hemoglobin E-beta thalassemia
Disseminated intravascular coagulation
|D66||Hereditary factor VIII deficiency [excludes factor VIII deficiency with vascular devect (D68.0-)]|
|D67||Hereditary factor IX deficiency|
Von Willebrand disease, unspecified [excludes abnormal coagulation profile NOS (R79.1)]
Von Willebrand disease, type 1
Von Willebrand disease, type 2A
|D68.021||Von Willebrand disease, type 2B|
|D68.022||Von Willebrand disease, type 2M|
|D68.023||Von Willebrand disease, type 2N|
|D68.029||Von Willebrand disease, type 2, unspecified|
|D68.03||Von Willebrand disease, type 3|
|D68.04||Acquired von Willebrand disease|
|D68.09||Other von Willebrand disease|
Antiphospholipid antibody with hemorrhagic disorder
Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
Hemorrhagic disorder due to extrinsic circulating anticoagulants
Acquired coagulation factor deficiency
Activated protein C resistance
Prothrombin gene mutation
Other primary thrombophilia
Lupus anticoagulant syndrome
Other specified coagulation defects
Coagulation defect, unspecified
Non-immune heparin-induced thrombocytopenia, type 1
|D75.822||Immune-mediated heparin-induced thrombocytopenia, type 2|
|D75.828||Other heparin-induced thrombocytopenia syndrome|
|D75.829||Heparin-induced thrombocytopenia, unspecified|
|D75.84||Other platelet activating anti-PF4 disorders
Use additional code, if applicable, for adverse effect of other viral vaccine (T50.B95-)
. American Society of Hematology. Hematology.org. https://www.hematology.org/.
. Local Coverage Determination (LCD): Hemophilia Clotting Factors. CMS.gov. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=33684&ver=46.
. Coagulopathy and Perioperative Hemorrhage and Hematoma (PSI-9). ICD10monitor.com. https://icd10monitor.com/coagulopathy-and-perioperative-hemorrhage-and-hematoma-psi-9/.
. 2022 ICD-10-CM Codes D50–D89. ICD10data.com. https://www.icd10data.com/ICD10CM/Codes/D50-D89.
Updated on March 1, 2022
Chronic obstructive pulmonary disease (COPD) is a progressive chronic respiratory disease that causes blocked airways and breathing-related problems. COPD can be caused by long-term exposure to harmful particles or gases that irritate the lungs such as tobacco smoke and exposure to air pollution.
Types of COPD
Chronic bronchitis — hypersecretion of mucus with chronic productive cough lasting more than 3 months in 2 consecutive years
- Simple — non obstructive; smokers cough (J41.0)
- Mucopurulent — production of sputum containing mucus and pus (J41.1)
- Mixed — chronic simple and mucopurulent bronchitis (J41.8)
- Chronic bronchitis, NOS (J42)
Emphysema — enlarged or over inflated air space in the lung due to damaged alveoli (air sacs) or alveolar wall resulting in breathing difficulty and increased risk of respiratory infections.
- Unilateral pulmonary emphysema – MacLeod’s syndrome (J43.0)
- Panlobular — affecting lower lobes (J43.1)
- Centrilobular — affecting upper lobes (J43.2)
- Other and Unspecified (J43.8, J43.9)
Chronic obstructive pulmonary disease — chronic bronchitis and emphysema causing irreversible airflow obstruction
- With (acute) respiratory infection (J44.0)
- With (acute) exacerbation (J44.1)
- COPD, unspecified (J44.9)
Stages of COPD
80% or greater
Persistent, dry cough; shortness of breath during exertion
79% - 50%
Persistent cough with excess mucus, shortness of breath during mild activity, wheezing, fatigue, and sleep disturbance
49% - 30%
Frequent respiratory infections, edema, cyanosis, tightness in chest, trouble breathing while performing basic tasks, and difficulty taking a deep breath
29% or less
Constant wheezing and shortness of breath, inability to inhale deeply increased heart rate and blood pressure, and loss of appetite and weight
COPD Treatment and Management
There is no cure for COPD, but early intervention can slow the disease progression and reduce the risk of complications. Treatment for COPD can include:
- Antibiotics — fights bacterial infection
- Bronchodilators — opens airways
- Bullectomy — removal of air space from collapsed air sacs
- Corticosteroids — reduces inflammation
- Lung transplant — replace diseased lung with a healthy one
- Lung volume reduction — removes diseased lung tissue
- Oxygen therapy — reduces shortness of breath
- Pulmonary rehabilitation — includes disease management, exercise, and counseling
- Smoking cessation — slows progression
- Vaccines — lower risk of flu or pneumonia
Asthma is a chronic lung disease causing inflammation and constriction of the airways that affects the ability to breathe. Asthma triggers may be different for each person and can change over time. Different triggers cause different types of asthma.
- Allergic — Dust mites, mold, pollen, pets, household pests, etc.
- Non-allergic — Cold air, medications, household chemicals, air pollution, tobacco smoke, infection, etc.
- Exertional — Induced by exercise or physical activity.
- Occupational — Caused by breathing chemicals or industrial dust particles at work.
Asthma is classified by frequency and severity of symptoms as well as complications of the disease: (J45.-)
- Mild, moderate, severe
- Intermittent, persistent
- Uncomplicated, with acute exacerbation, with status asthmaticus
Document diagnostic test results and any clinical findings that support the diagnosis, along with disease status and treatment plan.
- Bronchoprovocation — tests pulmonary response or reaction to the drug methacholine.
- Bronchoscopy — procedure using a small camera on the end of a long flexible tube, or scope, to look at air passages
- Chest x-ray — imaging test to look at the structures and organs of the chest
- Computed tomography (CT) scan — computerized digital scan that creates two-dimensional, cross-sectional images
- Endobronchial Ultrasound (EBUS) — bronchoscopy performed using scope with an ultrasound probe attached
- Fractional exhaled nitric oxide (FeNO) test — measures levels of nitric oxide exhaled from a breath
- Lung biopsy — procedure to collect a tissue sample used in disease diagnosis
- Peak Expiratory Flow (PEF) — measures speed of air blown out of the lungs using maximum effort
- Pulse oximeter (Pulse Ox) — measures the saturation of oxygen carried in your red blood cells
- Spirometry — measures volume capacity and the force of air expelled from the lungs
A diagnosis is not supported by the simple reference of a diagnostic study. The provider must interpret the results and include the clinical significance in the medical record
Coding and Documentation
ICD-10 code assignment depends on documentation details that should include:
- Specific diagnosis
- Severity, frequency, or complication
- Condition status and controlling agents
- Causal relationships
- Coexisting and/or underlying conditions
Refer to the tabular list for guidance on diagnosis inclusions, exclusions and additional coding notes.
Use Additional Codes to identify:
- Exposure to environmental tobacco smoke (Z57.31, Z77.22)
- Tobacco use (Z72.0), tobacco dependence (F17.-), or history of tobacco dependence (Z87.891)
- Dependence on supplemental oxygen (Z99.81); use of long-term supplemental oxygen regardless of the duration each day
- Dependence on respirator [ventilator] (Z99.11); use of respirator or ventilator for life support
- Long-term (current) use of inhaled or systemic steroids (Z79.5-)
- Other diseases of the pleura (J90-J94)
- Intraoperative and post procedural complications and disorders of respiratory system (J95)
- Other diseases of the respiratory system (J96-J99)
 AHA Coding Clinic, 2002, Q4,
AMB21-AR-H-143 Updated on November 15, 2021
Condition status Z codes are informative and distinct from “history of” codes. “History of” codes indicate a past condition has been resolved and is not present. Condition status codes indicate that a patient is either a carrier of a disease or has the sequela or residual of a past disease or condition. The status can affect the course of treatment and its outcome but they are commonly overlooked. 
Amputation Status — Category Z89
Codes in Category Z89 describe traumatic or post-procedural absence of a limb, when there are neither complications of the amputation nor treatment directed toward the site. Documentation should include anatomical location and laterality.
Artificial Opening Status — Category Z93
Codes in category Z93 describe functional artificial opening status. Artificial openings can be permanent or temporary depending on circumstances of creation. These codes are appropriate when no treatment is directed at the site. Documentation should include date of initial procedure and/or reversal, if applicable.
Organ Transplant Status — Category Z94
Category Z94 codes identify post-transplant status when there are no complications of the transplanted organ. A code from this category is appropriate as an additional code when treatment of a condition does not affect the function of the transplanted organ.
Supplemental Oxygen or Respirator Dependence – Category Z99
Category Z99 codes identify supplemental oxygen or ventilator dependence status when there is no complication or malfunction of the equipment on which the patient is dependent. Dependence status can be for a short or long period of time in the hospital, another medical setting, or at home. Dependence on supplemental oxygen status is appropriate for any patient using long-term supplemental oxygen, regardless of the duration of use each day. Use dependence on respirator [ventilator] status codes when respiratory device or equipment is for life sustaining support.
Renal Dialysis Status
ICD-10-CM includes codes for dependence on renal dialysis and noncompliance with renal dialysis. These codes are appropriate when the presence of AV shunt for renal dialysis is indicated.
Lifelong Chronic Conditions
Lifelong chronic conditions often require ongoing medical attention and the associated diagnoses are typically unresolved once diagnosed. It is appropriate to report these conditions, even when stable, if documented in any part of the medical record at the time of the encounter.
|Condition Description||ICD-10 Diagnosis|
|HIV/AIDS||B20 , Z21|
|Hemolytic Anemias||D56.0, D56.1, D56.5, D57.0-D57.1|
|Disorders of Immunity||D81.0 - D81.7, D81.89, D81.9, D82.0 - D82.1, D83.1, D84.1|
Coagulation Defects and Hemorrhagic Conditions
|Metabolic Disorders||E70.0 - E72.9, E74.0 - E74.2, E74.4 - E74.9, E75.00 - E75.4, E76.01- E77.9, E78.71 - E78.72, E79.1 - E79.9, E80.0 - E80.3, E84 - E85, E88.01, E88.4-, E88.89|
|Pervasive Developmental Disorders||F84.-|
|Systemic Atrophies Primarily Affecting the Central Nervous System||G10 - G12.9|
|Extrapyramidal and Movement Disorders||G20 - G23.9|
|Degenerative Diseases of the Nervous System||G31.81 - G31.83|
|Demyelinating Diseases of the Central Nervous System||G36.0, G37.0|
|Diseases of Myoneural Junction and Muscle||G71.0 - G71.11, G71.2|
|Cerebral Palsy and Paralytic Syndromes||G80.-, G82.-|
|Other Disorders of the Nervous System||G90.1, G90.3, G93.7|
|Congenital Malformations||Q00.0 - Q02, Q04.0 - Q07.9, Q65.-, Q77.0 - Q78.9, Q79.6-, Q86.-, Q87.1 - Q87.89, Q84.4, Q89.8|
|Chromosomal Abnormalities||Q90.0 - Q93.9, Q95.2 - Q95.3, Q96.0 - Q99.9|
It is important to include all condition details in documentation. Report all applicable Z status codes and chronic condition diagnosis codes.
- When presence affects medical decision making or a pertinent factor of overall health.
- During a wellness or physical exam, at least once per calendar year for as long as they exist.
 ICD-10-CM Chapter 21: Factors influencing health status and contact with health services
 ICD-10 Diagnosis
Heart Failure is a chronic, progressive condition in which the heart is unable to pump enough blood to meet the body's needs for blood and oxygen. Heart failure is usually caused by another condition that either damaged the heart or caused it to work too hard.
- Coronary artery disease
- Congenital heart disease
- Sleep apnea
- Severe lung disease
Signs and Symptoms
- Edema in the feet, ankles, and legs
- Fatigue, weakness, or lightheadedness
- Irregular or fast heartbeat
- Dyspnea, orthopnea, or persistent coughing
- Confusion, impaired thinking, or decreased ability to concentrate
Types of Heart Failure
Heart failure can affect either the heart’s left or right side, or both sides, and it can be acute, chronic, or acute-on-chronic.
- Left-sided heart failure or left ventricular (LV) heart failure – Failure of the left ventricle, the main pumping chamber of the heart, to pump blood out to the body effectively. Accumulation of excess fluid behind the left ventricle causes dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and/or acute pulmonary edema.
There are two different types of left-sided heart failure which call for different treatment approaches:
- Systolic heart failure — Heart failure with reduced ejection fraction (HFrEF) – the left ventricle loses its ability to contract normally. The heart can’t pump with enough force to push enough blood into circulation.
- Diastolic heart failure — Heart failure with preserved ejection fraction (HFpEF) – the left ventricle loses its ability to relax normally because the muscle has become stiff. The heart can’t fill properly with blood during the resting period between each beat.
- Right-sided heart failure, or right ventricular (RV) heart failure — Failure of the right ventricle to move blood returning from systemic circulation into the lungs. Blood backs up in the body’s veins, causing systemic venous congestion (distended neck veins), pitting edema of the lower extremities or other dependent portions of the body, enlarged tender liver, and/or ascites.
- Chronic heart failure develops slowly and the onset of symptoms may be gradual. Treatment is aimed at managing the underlying cause, minimizing symptoms, and preventing the heart failure from becoming worse.
- Acute heart failure develops suddenly, and symptoms are initially severe which may be experienced until the underlying condition is identified and treated. This can happen with:
- Severe anemia
- Pulmonary embolism
- Severe infections or allergic reaction
- Acute on chronic heart failure occurs when there is an acute decompensation of chronic heart failure.
Coding and Documentation
When documenting heart failure, include the following:
- Type — systolic, diastolic, etc.
- Acuity — acute, chronic, etc.
- Disease status — stable, improved, etc.
- Treatment plan — medicines, lifestyle changes, etc.
Code all documented conditions present at the time of the encounter that require or affect patient care, treatment or management. This includes stable chronic conditions and comorbidities. Include the ICD-10 coded to the highest specificity on the claim.
“Exacerbated” or “Decompensated”
Coding guidelines advise that “exacerbation” and “decompensation” indicate an acute flare-up of a chronic condition. When systolic or diastolic heart failure is described in these terms, the appropriate code indicating acute on chronic heart failure should be assigned.
Congestive heart failure
The term congestive heart failure refers to the back up of fluid into the lungs and tissues. Assign code I50.9, heart failure NOS for a diagnosis of unspecified congestive heart failure.
When documentation links either systolic or diastolic dysfunction with heart failure, report as systolic/diastolic heart failure. Link CHF to other associated conditions unless specifically documented as “unrelated”.
- Chronic kidney disease (CKD)
ALL21-AR-H-084 Updated on October 20, 2021
Diabetes is a disease that occurs when glucose in the blood (blood sugar) is not controlled due to a malfunction of the body’s insulin production. Insulin is necessary to break glucose so that it can enter the body’s cells. High blood sugar from diabetes can lead to other major health problems.
Signs and Symptoms
- Frequent urination
- Increased thirst or higher water intake
- Constant hunger, even after eating
- Extreme fatigue
- Slow-healing wounds or bruises
- Unexplained weight loss
- Tingling, pain, or numbness in hands/feet
- Blurry vision
Diabetes Type & ICD-10-CM Category,
- Type I — Category E10
- Insulin-dependent - the body does not produce insulin
- Sometimes called juvenile diabetes because it usually develops during childhood or adolescence.
- Sudden onset of symptoms
- Type II — Category E11
- The body does not use the insulin it produces efficiently
- Symptoms gradually progress.
- Treatment may include a combination of medications, exercise, and diet.
- Gestational — Category O24
- Insulin produced by mother is blocked by pregnancy hormones increasing blood sugar.
- Excess glucose is sent to the fetus and stored as fat.
- Typically resolves once the baby is born.
- Glucose intolerance that develops from disorders or conditions other than type 1, type 2, or gestational diabetes.
- Due to underlying condition (E08.-)
- Drug or chemical induced (E09.-)
- Other specified diabetes, NEC (E13.-)
Coding and Documentation
The provider should document all known condition details and state the specific diagnosis. Document test results and any clinical findings that support diabetes along with disease status and treatment plan.
Assign the ICD-10-CM code to the highest level of specificity found in the medical record.
Diabetes combination codes include:
- Type of diabetes
- Body system affected
- Complication/manifestation affecting the body system
The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List.
- Any condition indexed under “With” does not have to be linked by the provider. If the “with” condition is unrelated to diabetes, it must be specifically documented.
- The link must be documented when a relationship exists between diabetes and another condition not found under “With” before assigning the diabetic complication code.
- A patient may have diabetic complications in more than one body system. Report as many codes from categories E08 — E13 as are needed to identify all associated conditions.
Follow ICD-10 coding guidelines for code assignment and sequencing. Report codes for diabetic manifestations, underlying conditions, and the controlling agents when instructed.
Link must be documented
|chronic kidney disease, glomerulonephritis, glomerulosclerosis, Kimmelsteil-Wilson disease, nephropathy, renal tubular degeneration||Renal complications NEC, microalbuminuria, proteinuria|
|Cataract, retinopathy, macular edema, retinal detachment||Ophthalmic complication NEC, blindness, glaucoma, retinal ischemia, vitreous hemorrhage, rubeosis iridis|
|Amyotrophy, autonomic (poly)neuropathy, gastroparalysis, gastroparesis, Loss of Protective Sensation (LOPS), mononeuropathy, myasthenia, neuralgia, neuropathy, polyneuropathy||Neurologic complication NEC, cranial nerve palsy, neuropathic ulcer|
Gangrene, peripheral angiopathy, (PVD/PAD) with or without gangrene
|Circulatory complication NEC, coronary artery disease, hypertension|
|Charcot's joints, dermatitis, foot ulcer, hyperglycemia, hypoglycemia, necrobiosis lipoidica, neuropathic arthropathy, osteomyelitis, periodontal disease||
Arthropathy NEC, oral complication NEC, skin complication NEC, other specified complication NEC, cellulitis, erectile dysfunction, obesity, high cholesterol
- Acute renal failure N17.9
- Chronic Kidney Disease (CKD) N18.-
- Glaucoma H40-H42
Use Additional Code:
- Use of insulin, Z79.4
- Use of oral antidiabetic drugs, Z79.84
- Use of non-insulin injectable drugs, Z79.899
Poor Control and Uncontrolled
The terms “poor control” and “uncontrolled” are not interchangeable. Poorly controlled diabetes refers to diabetic hyperglycemia. There is not an index reference for “uncontrolled” diabetes. If hyperglycemic or hypoglycemic is not specified, the default code, E11.9 (diabetes, unspecified), is assigned.
 AHA Coding Clinic, Q1 2017 Pg. 42
AMB21-AR-H-113 Updated October 22, 2021
Occasionally, a reported diagnosis may be omitted from a claim due to errors or limitations of electronic claims submission. Improve the capture of risk adjustment conditions by entering the diagnosis codes on the claim correctly.
Diagnosis “pointers” connect the diagnosis made by the provider to each CPT® code billed on the claim. Only four (4) diagnosis pointers can be listed per CPT® code.
- Identify the 4 most important or serious diagnoses that the procedure is intended to treat.
- Enter the diagnosis pointers in order of severity.
Maximize reporting opportunities:
Avoid missing eligible risk adjustment conditions by thorough documentation and accurate diagnosis coding.
- Address all conditions present at the time of the encounter that require treatment or management.
- Report all chronic conditions that impact treatment or care, even if stable. This includes pertinent status codes.
- Explicitly state each diagnosis and provide documented evidence of support in the medical record.
- Capture all valid ICD-10 diagnosis codes in the appropriate order on the claim form.
Always follow the current ICD-10-CM Official Guidelines for Coding and Reporting Refer to the Medicare Claims Processing Manual2 for additional information.
1500 Claim Form Instructions (PDF) — Coming soon
Health Insurance Claim Form (PDF) — Coming soon
- Result from a face-to-face encounter with acceptable provider in an acceptable setting type.
- List the complete date of service (month/day/year).
- Contain at least two patient identifiers on EACH page of every document (Name, DOB, MRN).
- Include legible, handwritten signature with credentials or proper EMR electronic authentication.
- Explicitly state the diagnosis, and clearly document supporting evidence of an active/current condition.
Assess the status of conditions for which interventions are recommended or underway. Code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care treatment or management. This includes ongoing chronic conditions, even if stable.
Documentation from past dates of service may not be used to report codes for the current date of service.
MEAT and TAMPER are used as tools to help coders determine if a condition can be coded as current or active. At least one of the following elements must be present in at least one section of the medical record (Subjective, Objective, Assessment, Plan) to substantiate the presence of a condition:
- Monitor, Evaluate, Assess/Address, Treat
- Treat, Assess, Monitor/Medicate, Plan, Evaluate, Refer
Do not code conditions that have been treated or no longer exist. Documentation where the provider has used the term(s) “history of” will be coded using the appropriate diagnosis code for the historical condition. The condition should not be referenced as a “history of” if it is a chronic condition currently undergoing treatment.
Conditions mentioned in Past Medical History or Active Problem List must be supported in another section of the medical record in order to verify the condition is active. The best practice is to include evidence of current review in the form of medication, referrals, order of lab tests, etc. in the assessment and plan.
Document to the highest degree, and code to the highest specificity. The ICD-10 diagnosis code must match the wording used in documentation. Explicitly state the diagnosis and follow the official conventions and guidelines for coding and reporting.
Be clear and consistent throughout the medical record when documenting details of a condition. A diagnosis cannot be validated when the record contains conflicting information.
When a condition is assessed and documented in a face-to-face encounter, include the corresponding ICD-10 diagnosis code on the claim form submitted to the health plan.
Telemedicine Visits provided via synchronous audio and video technology meet the face-to-face requirement for risk adjustment. Documentation must include that the visit was performed using interactive audio/video with real-time, two-way communications. Virtual Check-Ins, E-Visits, and Telephone Visits are not acceptable.
 Medicare has expanded telehealth coverage and eased current restrictions for the duration of the COVID-19 crisis. During this time, telehealth services that meet the face-to-face documentation requirements can be used for risk adjustment.
 Telehealth (PDF)
 ICD-10-CM Official Guidelines for Coding and Reporting (PDF)
The Official ICD-10-CM Guidelines are the authoritative source for diagnosis coding and documentation. Please refer to the current year’s guidelines for detailed instructions. These guidelines and other information about risk adjustment can be found on CMS’s website.
Follow the guidelines and assign the appropriate combination codes when reporting hypertension and another condition.
The relationship between hypertension, heart disease and chronic kidney disease is assumed when conditions are found together, unless explicitly documented unrelated.
Applies to conditions found in I50.-, I51.4-I51.7, I51.89, I51.9 Category I11 — Hypertensive Heart Disease
- Code separately only if heart disease stated "Not due to hypertension."
- Use additional code from category I50, Heart Failure, if applicable
Category I12 — Hypertensive Chronic Kidney Disease (CKD)
- Code separately only if documentation specifies cause other than hypertension
- Use additional code to identify the stage of the CKD
- Also code dialysis status, if applicable
Category I13 — Hypertensive Heart and Chronic Kidney Disease
- Do NOT separately code for hypertension, heart disease, and chronic kidney disease or assign with codes from categories I11 or I12
- Use additional code for heart conditions I50.-, I51.4-I51.7, I51.89, I51.9
- Also code the appropriate stage of CKD (N18.- ) and dialysis, if applicable
For conditions not found under the term “with,” the relationship between hypertension and another condition must be specifically documented in order to code them as related.
Category I15 — Secondary Hypertension
Secondary hypertension is due to an underlying condition.
- Assign the code for the underlying condition and a code from category I15
Category I16 — Hypertensive Crisis
- Use a code from category I16 when hypertensive urgency, hypertensive emergency or unspecified hypertensive crisis is documented.
- Code also any identified hypertensive disease (I10- I15).
Category I27 — Pulmonary Hypertension
- Pulmonary hypertension is classified to category I27 — Other pulmonary heart diseases.
- Code any associated conditions or adverse effects of drugs or toxins also.
Hypertensive Cerebrovascular Disease
- Assign code from Categories I60-I69, followed by the appropriate hypertension code (I10-I15).
- Code H35.0 — Background retinopathy and retinal vascular changes with the applicable code from Categories I10-I15.
When a hypertension diagnosis has not been established, assign one of the following codes:
- R03.0 — Elevated blood pressure reading without hypertension.
- O13.- — Gestational [pregnancy-induced] hypertension without significant proteinuria.
- O14.- — Pre-eclampsia, for transient hypertension of pregnancy.
 ICD-10-CM Official Guidelines for Coding and Reporting FY 2022
AMB21-AR-H-116 Updated on October 21, 2021
Ischemic Heart Disease
Atherosclerosis is the buildup of fatty deposits, or plaque, within the coronary arteries. Plaque buildup causes narrowed or blocked blood vessels, which can lead to more serious conditions such as acute coronary syndrome and myocardial infarction.
Coronary atherosclerosis is categorized by the type of vessel in which it occurs:
- Native coronary artery
- Coronary artery bypass graft (CABG)
- Autologous or non-autologous artery or vein
- Other CABG
- Artery of transplanted heart
Atherosclerosis is also known as atherosclerotic heart disease (ASHD), coronary artery disease (CAD), or atherosclerotic cardiovascular disease (ASCVD).
- Poor diet
- High cholesterol
- Lack of exercise
- Family history
- Poor dental health
When documenting atherosclerosis, include the following:
- Location — Coronary artery involvement, vessel type
- Symptoms — Angina, shortness of breath, etc.
- Comorbid conditions — Hypertension, tobacco use, etc.
Angina is chest pain or discomfort caused when the heart muscle does not get enough oxygen-rich blood. It is usually a symptom of an underlying heart condition such as coronary artery atherosclerosis.
SIGNS and SYMPTOMS:
- Chest pain or discomfort, pressure, squeezing, or fullness in the center of the chest.
- Radiating pain in the arms, neck, jaw, shoulder, or back.
- Nausea, fatigue, shortness of breath, sweating, or dizziness.
TYPES and SEVERITY:
- Refractory — chronic angina that does not respond to medical treatment or intervention
- Stable — Pain that is usually caused by exertion or excitement and stops when at rest or with medication.
- Unstable — Pain changes in frequency, duration and intensity. Does not go away with rest or medicine.
- Variant — Coronary vasospasm that occurs most often while at rest. Associated with transient ST-segment elevation.
When documenting angina, include the following:
- Type — Stable, unstable, etc.
- Cause — Presumed to be ASHD, note if there is another cause
- Timing/precipitating factors — Exercise, emotional stress, etc.
- Relieving factors — Medications, rest, etc.
Not all chest pain is angina. “Angina” must be explicitly stated. Stable or asymptomatic angina that is controlled by a medication is an active condition and should be assessed, documented, and reported at least once per year. Use “history of” when the condition has resolved, and treatment is no longer needed.
Heart Disease Prevention and Management
Heart Disease Prevention and Management
|Low-fat and low-sodium diet
|Quit smoking||Calcium channel blocker||Angioplasty|
|Limit alcohol intake||Antianginals||Bypass|
|Moderate exercise, 30min/day||Beta blockers||Implant device
Myocardial Infarction (MI)
Myocardial infarction, known as a heart attack, is the permanent, gross necrosis of the myocardium (heart muscle tissue death). An electrocardiogram (ECG) reading will differentiate an ST elevation myocardial infarction (STEMI), or classic heart attack, from a non-ST myocardial infarction (NSTEMI), sometimes called a mild heart attack.
A heart attack occurs when a blocked artery interrupts blood flow to a section of the heart. If the blockage is not treated quickly, that part of the heart begins to die. Symptoms may be immediate and intense but typically start slowy and persist for hours, days or weeks before a heart attack. Report in acute/post-acute care setting or following transfer to another acute setting.
- Type 1 — Spontaneous
- Type 2 — Ischemic
- Type 3 — Unknown
- Type 4 — (3 subtypes, a-c)
- a — Due to percutaneous procedure
- b — Due to stent thrombosis
- c — Due to restenosis
- Type 5 — Due to CABG
- Myocardial Injury — non-ischemic; acute or chronic
Cardiac arrest is triggered by an irregular heartbeat (arrhythmia) affecting the heart’s ability to pump blood to other organs. Cardiac arrest occurs suddenly, often without warning. It is reversible if treated within the first few minutes but is fatal without quick intervention.
Category I20 — Angina Pectoris & Category I25 — Chronic ischemic heart disease
ICD-10-CM presumes a causal relationship between ASHD and angina when no other cause has been identified for the angina. These same conditions are coded separately when the provider has specifically documented a different cause for angina.
- I25.2, old MI — Healed myocardial infarction or MI older than four weeks (28 days).
Category I21 — Acute MI
- Type 1 — Initial myocardial infarction from onset up to four weeks (28 days) old.
- Unspecified AMI or unspecified type is assigned I21.9.
- Types 3-5 are coded I21.A9.
- Use code I5A for non-traumatic myocardial injury (acute, chronic, or non-ischemic)
Category I22 — Subsequent MI
- Occurrence of an acute MI within the four-week time frame of the initial acute MI.
- Code with a category I21 code.
Category I23 — Current complication following MI
- Must be coded with a Category I21 or Category I22 code.
- "Post-infarction angina” must be stated to assign (I23.7) as a current complication.
Category I24 — Acute ischemic heart disease
- Acute blood clots in the coronary arteries without myocardial infarction.
- Acute coronary syndrome (ACS).
 ICD-10-CM Category I25 expanded to include refractory angina effective October 1, 2022. FY2023 official coding guidelines and descriptions can be found at https://www.cms.gov/medicare/icd-10/2023-icd-10-cm
AMB22-AR-H-164 Updated on November 10, 2022
Major Depressive Disorder
Major Depressive Disorder, also known as clinical depression, is a common mood disorder characterized by a depressive episode having five or more symptoms causing significant distress or impairment (not caused by substance abuse or other conditions) lasting two or more weeks. At least one of the five symptoms must be depressed mood or loss of interest.
Symptoms of Depression:
- Depressed mood
- Feelings of worthlessness or guilt
- Fatigue or low energy
- Insomnia or hypersomnia
- Significant change in weight or appetite
- Loss of interest or pleasure in most or all activities
- Psychomotor retardation or agitation
- Recurrent thoughts of death or suicidal ideation
- Poor concentration
Depression screening tools, such as the PHQ-9, are used to identify the presence and level of severity.
0 — 4
None — Minimal
Education on available supportive services
5 — 9
Watchful waiting: Repeat PHQ-9 at follow-up visit
10 — 14
Treatment Plan: Consider Ccounseling and/or medication, follow-up visits
15 — 19
Active Treatment: Pharmacotherapy and / or psychotherapy, follow-up visits
20 — 27
Immediate initiation of pharmacotherapy, expedited referral to mental health specialist for psychotherapy and / or collaborative management
Bipolar disorder, sometimes called manic-depressive disorder, causes extreme shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. People with bipolar disorder experience periods of intense emotion, changes in sleep patterns and activity levels, and unusual behaviors. These distinct periods are called “mood episodes.” A provider would have to determine whether they may be the result of another cause (such as low thyroid, or mood symptoms caused by drug or alcohol abuse).
Symptoms of Mania:
- Talking more/faster than usual
- Inflated self-esteem (grandiose delusions)
- Extremely high energy and irritability
- More easily distracted
- Increased high-risk/reckless behavior
- Decreased need to sleep
Symptoms of Hypomania:
- Increased restlessness and irritability
- Extremely low energy and fatigue
- Decreased self-esteem
- Difficulty concentrating or making decisions
- Lasting sad, anxious, or empty mood
- Disturbance in sleep/wake cycle
Bipolar Type 1
Bipolar Type 2
|Marked by manic episodes||
Marked by hypomanic episodes
|Hospitalization due to mania likely||Hospitalization due to hypomania less likely|
|Psychosis may occur during manic episodes||Psychosis unlikely to occur during hypomania|
This disorder affects the way a person thinks, feels and acts. It makes it difficult to differentiate what is real and what is not. Symptoms vary by severity and type. All symptoms may or may not be present in individuals with the condition.
Symptoms of Schizophrenia:
- Lack of focus
- Difficulty completing tasks
- Extreme, disorganized thoughts
- Movement disorders
- Impaired memory
- Unmodulated speech
Coding and Documentation
Major depression and bipolar disorders are classified by their features (type, severity, and presence of psychosis).2 Symptoms can manifest differently from person to person. A patient’s complete overall health status requires accurate, detailed documentation of the provider’s assessment. 
- Active/Current — Provider assessment confirms the condition exists and the diagnosis is documented in the medical record. A patient can have a current diagnosis without being actively involved in treatment.
- “History of” — Patient has previously been diagnosed, the condition has completely resolved, and treatment is no longer needed. Past medical history (PMH)
Avoid using non-specific terms and unspecified codes when details of the condition are known.
Applicable to the current Bipolar Episode. 
- Manic Episode (F30.-)
Single manic, hypomanic or mixed bipolar episode.
- Type 1, Type 2, or Mixed (F31.-)
- Type 1 — Manic episodes (extreme up) lasting one week or longer. May also experience depressive episode for at least two weeks.
- Type 2 — Hypomanic episodes (extreme low) for four days and depressive episodes for two weeks.
- Mixed — Meets criteria for manic and depressive episodes almost every day for at least one week.
Applicable to the most recent Major Depressive Episode
- Single episode (F32.-) — By definition, “single episode” applies to the first episode and initial diagnosis of major depressive disorder. Single — Only one (1) in number, unique, sole*
ICD-10-CM CODE UPDATE: 
- Z32.A — Depression, unspecified — Applies to Depression, not otherwise specified (NOS)
Report F32.9, only if “major depressive disorder, single episode, unspecified severity, presence of psychosis unspecified” supported by provider documentation in the medical record.
- Recurrent episode (F33.-) — “Recurrent” applies to each subsequent episode and following encounter after the initial episode has resolved. Recurrent — Repeated; persistent; intermittent*
* Note: Sourced definitions
- Mild — five or six symptoms with mild disability, normal function requires substantially more effort than usual.
- Moderate — 7-9 symptoms with moderate functional impairment.
- Severe — 7-9 symptoms with major disability, inability to function in relationships with others and/or usual activities of day-to-day life.
- In remission — Patient has responded to treatment and no longer meets the criteria for clinical depression. The condition may or may not be currently managed by long term antidepressant medication and/or therapy services.
- Partial remission – No or minimal symptoms for less than two months
- Full remission – No or minimal symptoms for two months until treatment is complete and/or condition has resolved.
With or Without Psychotic Features
Specify the type and nature of the psychotic features:
Mood-congruent: Consistent with typical depressive theme
- personal circumstance
Mood-incongruent: Not consistent with typical depressive themes
- Thought insertion — Other persons thoughts in your head
- Thought broadcasting — Others can hear your thoughts
- Control — Own actions are under outside contro
- Persistent Mood Disorders (F34.-) — Symptoms present for most days during the past two years not meeting all criteria for major depressive or bipolar disorder.
- Cyclothymia — Alternating and recurring periods of depression and hypomania
- Dysthymia — Persistent depression without psychosis. Mild to moderate chronic depression
- Schizophrenia (F20.-) - Categorized by the manifestation:
- Other and unspecified
- Category F01-F09 — Mental disorders due to known physiological conditions· Schizoaffective Disorders (F25.0) — Characterized by having symptoms of both schizophrenia and mood disorders (depression, bipolar disorder) alternating from delusions or hallucinations to the predominant mood disorder symptoms during the active period of the condition.
- Category F10-F19 — Mental and behavioral disorders due to psychoactive substance use.
Behavioral Health Provider Types Valid for Risk Adjustment Reporting
Provider Specialty Codes describe the kind of medicine physicians, non-physician practitioners or other healthcare providers/suppliers’ practice.
- Provider Specialty Code & Description
- 26 - Psychiatry
- 27 - Geriatric Psychiatry
- 62 - Psychologist
- 68 - Clinical Psychologist
- 80 - Licensed Clinical Social Worker
- 86 - Neuropsychiatry
- D5 - Opioid Treatment Program
Provider Credentials signify a health care provider is a licensed practitioner and the area of specialization.
- Provider Credential & Description
- LISW - Licensed Independent Social Worker
- LCSW - Licensed Clinical Social Worker
- MD, DO - Psychiatry
- Ph.D. - Doctor of Philosophy, can also be psychologists
- PSY.D -Doctor of Psychology
- PMHCNS-BC - Adult Psychiatric-Mental Health Clinical Nurse Specialist
- PMHNP-BC - Psychiatric-Mental Health Nurse Practitioner
 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth edition, 2013
 The Patient Health Questionnaire Screener Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute
 Bipolar Disorder
 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth edition, 2013
 International Classification of Diseases 10th Revision Clinical Modification ICD-10-CM Official Guidelines for Coding & Reporting
 Codes for Depression (F32-F33) and Bipolar (F30-F31) are not reported together. See “Excludes 1 & 2” category guidelines.
 Effective 10/1/2021
AMB21-AR-H-144 Updated on November 15, 2021
Neoplasms and Cancer
A neoplasm is an abnormal growth or mass of cells called a tumor. Tumor growth, or behavior, can be benign (non-cancerous) or malignant (cancerous). Benign tumors grow in one place and do not spread to other body parts. Malignant tumors grow, spread, and invade other body parts (metastasis).
Types of Cancer
Cancer can start almost anywhere in the human body. Primary cancer refers to the origin of a malignant neoplasm. Metastatic cancer, or secondary cancer, is the formation of a new tumor in a secondary site from the metastasis of the primary cancer.
Cancer is usually classified by the location it started (i.e. lung cancer, colon cancer, breast cancer, etc.) or the type of cell where it was formed.
- Carcinoma — Epithelial cells, cells covering inside or outside surfaces
- Sarcoma — Bone and soft tissue, includes muscle, fat, blood and lymph vessels, tendons and ligaments
- Leukemia — Bone marrow
- Lymphoma — Lymphocytes (T cells & B cells), white blood cells
- Myeloma — Plasma cells
- Melanoma — Melanocytes, melanin producing cells (pigmented tissue such as skin or eyes)
Detection & Staging
Cancer staging is based on the extent of the tumor. Laboratory studies of blood, urine, and stool to detect abnormalities that may indicate cancer. Imaging tests such as X-rays, CT, MRI, ultrasound, and fiber-optic endoscopy help determine the suspected cancer’s location and size. A biopsy can confirm the diagnosis of most cancers, and other tests can provide specific information about the cancer.
The stage of cancer indicates information about the location, cell type, size, and grade, and if it has spread to a different part of the body. A cancer is always referred to by the stage it was given at diagnosis regardless of progression or regression.
Carcinoma in situ
Stage I, II, and III
Abnormal cells present but confined to the point of origin without invasion of the surrounding normal tissue
Cancer is present. The higher the number, the larger the cancer tumor and the more it has spread into nearby tissues.
Cancer has grown very extensive and/or has spread to distant parts of the body.
Treatment depends on the cancer type, and how advanced it is. Malignant tissue can be removed with surgical excision or treated using targeted therapy, precision medicine, or stem cell transplant.
Targeted Therapy — Use of drugs to attack specific types of cancer cells with less harm to normal cells.
Precision Medicine — Use of genetic and environmental proteins to treat the cancer
Stem Cell Transplant — Cancerous bone marrow is replaced with healthy bone marrow from a donor.
Coding & Documentation
Clearly document all know details of the patient’s condition. This should include:
- Behavior — Malignant, Benign,
- Location — Site specific (cell type, anatomical location, laterality)
- Type — Primary, Secondary (include cancer stage)
- Status — Active, In remission, "History of"
For active cancers, document the current treatment. If patient has refused treatment or is under watchful waiting, document the reason and disease progress.
If the patient receives adjuvant therapy, indicate if it is for treatment or prophylactic purposes.
Also report the type of cancer treatment used:
- Radiation Therapy (Z51.0)
- Chemotherapy (Z51.11)
- Immunotherapy (Z51.12)
- Hormone Therapy (Z79.890)
When assigning the diagnosis for neoplasms and cancer, refer to the Neoplasm Table found in the alphabetic index first, unless the histological term is documented (ex. Adenoma). The terms “lump” or “mass” should never be indexed to the neoplasm table. The index directs a coder to see “mass” instead.
- Neoplasm that overlaps two or more contiguous sites should be coded (overlapping lesion) unless specifically classified elsewhere.
- When treatment is directed at the malignancy, make the malignancy the principal diagnosis.
- If the encounter is solely for the administration of chemotherapy, immunotherapy, or radiation therapy, assign a code from category Z51- first.
- When treatment is directed toward a secondary site only, the secondary neoplasm is designated as the principal diagnosis.
Active vs. Historical
Documentation should clearly indicate and provide support for the current condition.
Do not code “history of” when cancer is currently active or assign a code for active cancer if the disease has been treated and no longer exists.
Report a code for active cancer when documentation supports:
- Current treatment or patient’s refusal of treatment
- Further treatment is directed towards site of excised malignancy
- Watchful waiting
History of cancer should be reported as personal history of malignant neoplasm with the appropriate code from category Z85- when documentation supports:
- Malignancy has been removed, treatment was completed or and/or patient is being monitored for a recurrence.
- There is no evidence of disease and no further treatment being directed towards site.
- Adjuvant therapy is for prophylactic purposes.
Leukemia, multiple myeloma and malignant plasma cell neoplasms, have codes indicating whether the cancer has achieved remission status, or is in remission.
- Z85.6 Personal history of leukemia is only used when the physician documents that the patient has been completely cured
 National Cancer Institute
AMB21-AR-H-109 Updated on October 18, 2021
Pregnancy is the period between conception and delivery in which a fetus develops inside the uterus. This time is divided into trimesters.
- 1st Trimester: Less than 14 weeks
- 2nd Trimester: 14 weeks-28 weeks
- 3rd Trimester: 28 weeks-delivery
Gestational age is the age of the developing fetus. It begins on the first day of the mother’s last menstrual period and ends at birth (~40 weeks). Document the gestation in weeks and days
Childbirth begins with the true onset of labor and ends after the delivery of the baby and placenta. This is divided into three stages for vaginal deliveries.
- Begins with onset of contractions.
- Ends when cervix is dilated 10 cm.
- Begins when cervix is fully dilated.
- Ends with delivery of baby.
- Begins after the baby is delivered.
- Ends after placenta delivery.
- Puerperium — The approximately 6 week period after delivery when the mother’s body adjusts back to a non-pregnant state.
- Products of conception — Tissues that develop during pregnancy (fetal tissue, placenta tissue, etc.).
- Ectopic — A pregnancy that implants outside of the uterus.
- Abortion — Premature induced or spontaneous passing of the products of conception
- A spontaneous abortion, or miscarriage, is the spontaneous loss of the fetus before the 20th week of pregnancy.
- A missed abortion refers to a delayed miscarriage.
- A threatened abortion refers to a hemorrhage in early pregnancy.
- Perinatal — The period of time before birth through the 28th day following birth.
- Congenital — A condition that is present from birth.
Coding and Documentation
It is important to document condition details to the highest known degree so the diagnosis can be coded to the highest specificity. Documentation should include:
- Patients' pregnancy by week of gestation.
- Normal or high-risk pregnancy and reason for being high-risk, if applicable.
- Underlying or pre-existing conditions.
- Number of fetuses, if multiple, and number or alpha assigned to each (e.g., 1-8, A-H).
- Delivery outcome and location of delivery.
- Normal, full-term, uncomplicated.
Specify any complications and fetal presentation.
Include the diagnosis in the Assessment and Plan when a condition and the supporting evidence is documented during a face-to-face encounter. Include the ICD-10 Diagnosis Code for all documented conditions on the claim form. This includes chronic conditions, even if stable.
Encounter for Delivery:
- Full-term, uncomplicated, vaginal delivery
- C-section without indication
- Other malposition
Labor & Delivery Complications:
- Cord around neck
- First-fourth degree perineal laceration
- Rupture of uterus during labor
ICD-10-CM Guidelines for Coding & Reporting
Chapter 15 — Pregnancy, Childbirth, and the Puerperium (O00-O9A)
- Chapter 15 codes have sequencing priority over codes from other chapters.
- Use additional codes from other chapters to further specify conditions when applicable.
- Use codes O00-O9A only on the maternal record, never on the record of the newborn.
- A code from Category Z34, Encounter for supervision of normal pregnancy, should be used as the first-listed diagnosis for routine outpatient prenatal visits when no complications are present.
- Report code Z33.1, Pregnant state, incidental, when pregnancy is documented as incidental to the encounter instead of codes from Chapter 15.
- It is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.
- The provider’s documentation of the number of weeks may be used to assign the appropriate code identifying the trimester.
- A code from Category O09, Supervision of high-risk pregnancy, should be used as the first-listed diagnosis for routine prenatal outpatient visits for patients with high-risk pregnancies.
- Use only during the prenatal period.
- Use applicable Chapter 15 codes for complications during the labor or delivery episode as a result of a high-risk pregnancy.
- When there is an “in childbirth” option for the obstetric complication being coded, the “in childbirth” code should be assigned.
- Code the appropriate encounter for full-term uncomplicated delivery if there are no complications during the labor or delivery episode.
- Other Chapter 15 codes may be used in conjunction with these codes, if appropriate.
 ACOG Topics
AMB21-AR-H-148 Updated on November 16, 2021
Preventive visits are an important part of the process of keeping patients healthy. These visits improve quality of care and patient health outcomes by identifying patients who need disease management and intervention.
Annual Physical Exams
Annual Physicals or Routine Comprehensive Physical Exams (CPE) are performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury. The extent and focus of exam depends on the age and gender of the patient. An annual CPE includes an appropriate history/exam with risk counseling and/or intervention
Exam Description and CPT© Code:
Less than 1 year
5 -11 years
65 years and older
How should diagnosis codes be reported?
Category Z00 includes codes for Routine Health Exams with or without abnormal findings and should be the primary diagnosis. Report additional codes, if applicable, for pre-existing and chronic conditions, as well as newly discovered conditions and/or abnormalities documented during the routine exam, regardless of whether the finding requires an additionally reported service.
General adult medical examination:
Routine child health examination:
|Newborn and infant health examinations:
(as appropriate for age)
Follow the current year’s Official ICD-10-CM Guidelines for Coding and Reporting
What can be reported with the CPE?
• Other procedures
• Risk/Benefit Counseling
Tobacco smoking cessation counseling and substance abuse screening/intervention are included with CPE. Refer the current year’s CPT® Code book for further guidance and to view other services covered at the time of a preventive medicine exam.
Can preventive visits be performed on the same day as another visit?
A separately identifiable E/M service may be performed if prompted by symptoms or chronic conditions assessed during the AWV/CPE. Select the appropriate level of E/M services based on the following:
- The level of the medical decision making as defined for each service.
- The total time for E/M services performed on the date of the encounter.
Append modifier -25 to the E/M service (99202 – 99215) when performed on the same day as CPE (99381-99387, 99391-99397)
 ICD-10-CM Official Guidelines for Coding and Reporting (PDF)
All services provided require medical record authentication. Signatures may be handwritten or electronic. Rubber signature stamps are not acceptable, unless an exception has been granted due to a physical disability.
- Legible, hand written signature with credential — No date of signature required
- Hand-written signature or initials if provider name/credential on pre-printed progress note
- If the names of two or more physicians are listed on the note, then the provider must have his/her name identified, such as pre-printed name/credential.
- Initials over a typed or pre-printed name with credential.
- “Scribble,” as long as acceptable provider name with credentials is indicated.
- Digitalized signature: Handwritten and scanned into computer must be legible or provider name with credentials must be on record.
Electronic Signature Elements:
- Practitioner’s name
- Credentials noted
- Date signed *must be within 180 days of date of service
- “Last Updated” is an approved electronic signature date as long as the electronic signature wording is an approved authentication.
- If elements of the electronic signature are not met in its entirety, an attestation is needed.
- Practitioner credentials can be pre-printed anywhere within the DOS.
- Provider Signature authentication statement
- Provider name
- Provider credentials
- Date note signed:
- Note: To identify a transcribed note, look for indicators such as “Transcribed by,” “Date dictated (DD),” and/or “Date Transcribed (DT).”
(Not all inclusive)
- Accepted by
- Completed by
- Electronically signed by
- Released by
- Acknowledged by
- Confirmed by
- Electronically verified by
- Reviewed by
- Approved by
- Digitally signed by
- Encounter sign-off by
- Signature on file
- Authenticated by
- E-authenticated by
- Finalized by
- Authorized by
- Edited by
- Generated by
- Signed by
- Closed by
- Electronically generated
- Performed by
- Validated by
Reference: Medicare Program Integrity Manual (PDF)
Sepsis, Severe Sepsis, and Septic Shock
Sepsis is the immune systems extreme response to an infection. The chemical released into the bloodstream by the immune system attack the body instead of fighting the infection. Sepsis can quickly lead to tissue damage, organ failure and death. Early identification and treatment is critical.
- Septicemia or sepsis — Bacterial, viral or fungal infection in the bloodstream, also called blood poisoning.
- Inflammatory Response Syndrome (SIRS) - Systemic inflammation due to a blood born infection or other non-infectious cause such as trauma or injury.
- Severe Sepsis — Sepsis with systemic organ dysfunction, hypoperfusion (reduced blood flow) or hypotension (low blood pressure).
- Septic Shock — Severe sepsis with extreme, persistent hypotension and circulatory failure.
Signs and Symptoms
Sepsis may cause any of the following:
- Rapid breathing and heart rate
- Extreme pain or discomfort
- Shortness of breath
- Fever, shivering, or feeling very cold
- Confusion or disorientation
- Clammy or sweaty skin
- Nausea and vomiting
- Blotchy, pale, or discolored skin
Coding and Documentation
There is no single diagnostic test or comprehensive clinical criteria for sepsis. The diagnosis requires clinical judgment of the provider based on evidence of infection and organ dysfunction.
The level of detail in the documentation impacts coding and reporting accuracy.
- Identify the infectious agent or causal organism as well as the related infectious or non-infectious condition.
- Document the severity of the condition and including the organ(s) affected with the nature and severity of dysfunction.
- Specially state the causal relationship (due to/cause of) between sepsis and:
- Other infectious conditions
- Non-infectious conditions
- Post-procedural infections
To determine the proper code sequencing:
- Clearly state the reason for the hospital admission or the primary diagnosis.
- Note whether sepsis is present on admission or if it developed after admission, if not the cause.
Sepsis would not typically be assigned in the outpatient setting due to the acute nature of the condition.
Diagnosis Code Sequence
|USE ADD’L CODE||
WITH SEVERE SEPSIS
WITH SEPTIC SHOCK
|OTHER ADD’L CODE|
Present on admission
Acute organ dysfunction
Develops after admission
|USE ADD’L CODE||
WITH SEVERE SEPSIS
WITH SEPTIC SHOCK
|OTHER ADD’L CODE|
Do not code SIRS of non-infectious origin when infection and condition are related
|USE ADD’L CODE||
WITH SEVERE SEPSIS
WITH SEPTIC SHOCK
|OTHER ADD’L CODE|
Following infusion, transfusion and therapeutic injections
|Following a procedure||
(code to depth)
|Infection of obstetrical surgical wound||
(code to depth)
Refer to ICD-10-CM Official Guidelines for Coding and Reporting and review conventions in the tabular list:
- First, code for the underlying systemic infection. Use A41.9 Sepsis, unspecified organism, when the infection is not identified.
- Then use the appropriate codes to identify severe sepsis and septic shock.
- Additional code(s) for the associated acute organ dysfunction are required.
- Never assign severe sepsis or septic shock as principal diagnosis.
- Do not code severe sepsis unless severe sepsis or associated acute organ dysfunction is documented.
- Negative labs do not rule out sepsis when there is clinical evidence of the condition.
- Query provider when:
- Clinical evidence of sepsis is present with negative or inconclusive labs
- “Urosepsis” is documented
AMB21-AR-H-147 Updated on November 16, 2021
What Are Social Determinants of Health?
Social determinants of health are the conditions in the environments where people are born, live, learn, work, play, and age. These social factors can create significant barriers for a person’s wellness and health.
Who Can Collect SDoH Data?
Any member of a person’s care team can collect SDoH data. This includes providers, social workers, case managers, patient navigators, and nurses.
Why Is it Important to Collect SDoH Data?
This data allows our organization to develop and execute a coordinated and evidence-based strategy to improve population health.
Risk Adjustment Documentation and Coding Best Practices
The ICD-10-CM codes included in categories Z55–Z65 and Z75 identify non-medical factors that may influence a patient’s health status, such as their socioeconomic situation, including education and literacy, employment, housing, lack of adequate food or water, or occupational exposure to risk factors like dust, radiation, or toxic agents.
When providing services to a member, if social determinants are observed, the appropriate ICD-10-CM code(s) should be submitted on a claim. Including SDoH ICD-10 Z codes on the claims you submit will help to better strategize and address the social needs of our members.
The table below shows supplemental diagnosis codes and should not be used as the admitting or principal diagnosis code(s) to indicate the medical reason for the visit. The codes listed here are not all inclusive.
Category Problems/Risks Factors
Example Screening Questions
Z55 — Problems related to education and literacy
Z55.0 Illiteracy and low-level literacy
Z55.1 Schooling unavailable and unattainable
Z55.2 Failed school examinations
Z55.3 Underachievement in school
Z55.4 Educational maladjustment and discord with teachers and classmates
Z55.5 Less than a high school diploma
Z55.8 Other problems related to education and literacy
1. How would you rate your ability to read?
2. How confident are you in filling out medical forms by yourself?
3. How often do you have someone help you read hospital materials?
4. Are you concerned about your child’s learning performance or behavior in school?
Z56 — Problems related to employment and unemployment
Z56.0 Unemployment, unspecified
Z56.1 Change of job
Z56.2 Threat of job loss
Z56.3 Stressful work schedule
Z56.4 Discord with boss and workmates
Z56.5 Uncongenial work environment
Z56.6 Other physical and mental strain related to work
Z56.81 Sexual harassment on the job
Z56.82 Military deployment status
Z56.89 Other problems related to employment
1. What is your current work situation?
2. What is your occupation?
3. Do you ever have difficulty making ends meet at the end of the month?
Z59 — Problems related to housing and economic circumstances
Z59.1 Inadequate housing
Z59.2 Discord with neighbors, lodgers, and landlord
Z59.3 Problems related to living in residential institution
Z59.41– Food insecurity
(*Z58.6 lack of safe drinking water)
Z59.5 Extreme poverty
Z59.6 Low income
Z59.7 Insufficient social insurance and welfare support
Z59.81– Housing instability
Z59.82 Transportation insecurity
Z59.86 Financial insecurity
Z59.87 Material hardship
Z59.89 Other problems related to housing and economic circumstances
1. Are you worried or concerned that you may not have stable housing in the next two months?
2. In the last month, have you had concerns about the condition or quality of your housing?
3. Do you always have enough food for your family?
4. Do you have trouble paying your heating bill and/or electricity bill?
Z60 — Problems related to social environment
Z60.0 Problems of adjustment to lifecycle transitions
Z60.2 Problems related to living alone
Z60.3 Acculturation difficulty
Z60.4 Social exclusion and rejection
Z60.5 Target of (perceived) adverse discrimination and persecution
Z60.8 Other problems related to social environment
1. Do you have any concerns about discrimination or social exclusion for you or your family?
2. Have you recently experienced an event that has led you to feel lonely?
Z62 — Problems related to
Z62.0 Inadequate parental supervision and control
Z62.1 Parental overprotection
Z62.2– Upbringing away from parents
Z62.3 Hostility towards and scapegoating of child
Z62.6 Inappropriate (excessive) parental pressure
Z62.8 Other specified problems related to upbringing
Z62.81– Personal history of physical and sexual abuse in childhood
Z62.82– Parent-child conflict
Z62.89– Other specified problems related to upbringing
1. Do you feel emotionally safe where you currently live?
2. How often do you see or talk to people that you care about and feel close to?
3. In the past year, have you been humiliated or emotionally abused?
4. How often does anyone, including family, threaten you with harm?
5. How often does anyone, including family, scream or curse at you?
6. How often does anyone, including family, physically hurt you?
Z63 — Other problems related to primary support group, including family circumstances
Z63.0 Problems in relationship with spouse or partner
Z63.1 Problems in relationship with in-laws
Z63.3– Absence of family member
Z63.4 Disappearance and death of family member
Z63.5 Disruption of family by separation and divorce
Z63.6 Dependent relative needing care at home
Z63.71 Stress on family due to return of family member from military deployment
Z63.72 Alcoholism and drug addiction in family
Z63.8 Other specified problems related to primary support group
1. Do problems getting childcare make it difficult for you to work or study?
2. Have you recently suffered the loss or absence of someone close to you that has resulted in emotional distress?
3. How often do you get together with relatives?
4. Have you been discharged from the United States Armed Forces?
5. Are you concerned about someone in your home using drugs or alcohol?
Z64 — Problems related to certain psychosocial
Z64.0 Problems related to unwanted pregnancy
Z64.1 Problems related to multiparity
Z64.4 Discord with counselors
1. Do you have counseling resources available in your community?
2. In the last 12 months, have you engaged in any type of counseling in your community?
Z65 — Problems related to other psychosocial circumstances
Z65.0 Conviction in civil and criminal proceedings without imprisonment
Z65.1 Imprisonment and other incarceration
Z65.2 Problems related to release from prison
Z65.3 Problems related to other legal circumstances
Z65.4 Victim of crime and terrorism
Z65.5 Exposure to disaster, war, and other hostilities
Z65.8 Other specified problems related to psychosocial circumstances
1. In the past year, have you spent more than two nights in a row in a jail, prison, detention center, or juvenile correctional facility?
Z75 — Problems related to medical facilities and other healthcare
Z75.0 Medical services not available in home
Z75.1 Person awaiting admission to adequate facility elsewhere
Z75.2 Other waiting period for investigation and treatment
Z75.3 Unavailability and inaccessibility of healthcare facilities
Z75.4 Unavailability and inaccessibility of other helping agencies
Z75.5 Holiday relief care
Z75.8 Other problems related to medical facilities and other health care
1. How often is it difficult to get transportation to or from your medical or follow-up appointments?
2. Do you put off or neglect going to the doctor because of distance or transportation?
The above material is for informational purposes only and is not intended to be a substitute for a physician’s independent medical judgment. Physicians and other healthcare providers are encouraged to use their best medical judgement based on all available information and the condition of the patient in determining the best course of treatment.
AMB22-AR-H-157 Updated on November 10, 2022
In the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the American Society of Addiction Medicine created a category called substance use disorders. This category combines the concepts of “substance abuse” and “substance dependence” into a single disorder, measured on a continuum from mild to severe.
DSM-5 defines substance use disorder as a problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least two of the following occurring in a 12-month period:
DSM-5 Criteria for Substance Use Disorders
- Substance is often taken in larger amounts or over a longer period of time than was intended.
- Persistent desire or unsuccessful efforts to cut down or control substance use.
- Great deal of time spent in activities to obtain the substance, use the substance, or recover from its effects.
- Craving or strong desire to use the substance.
- Recurrent use resulting in failure to fulfill major role obligations at work, school, or home.
- Continued substance use despite persistent or recurrent social or interpersonal problems.
- Important social, occupational, or recreational activities are given up or reduced because of substance use.
- Recurrent substance use in situations in which it is physically hazardous.
- Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
- Tolerance, as defined by either of the following:
- A need for markedly increased amounts of the substance to achieve desired effect
- A markedly diminished effect with continued use of the same amount of substance
- Withdrawal, as manifested by either of the following:
- Characteristic withdrawal syndrome for the substance
- Use of the substance or closely related substance is taken to relieve or avoid withdrawal symptoms
Note: Symptoms of tolerance and withdrawal occurring in the context of appropriate medical treatment with prescribed medications (e.g., opioid analgesics, sedatives, stimulants) are specifically not counted when diagnosing a substance use disorder. Furthermore, the DSM states:
“The appearance of normal, expected pharmacological tolerance and withdrawal during the course of medical treatment has been known to lead to an erroneous diagnosis of addiction, even when these were the only symptoms present.”
Use, Abuse, and Dependence
Unlike DSM-5, ICD-10-CM continues to employ the concepts of substance abuse and substance dependence.
Substance abuse represents a maladaptive pattern of drug-taking, which may include detriments to social functioning, to physical well-being and/or to mental health in patients who have not yet reached a state of physical dependence.
Substance dependence is defined as a chronic mental and physical condition related to the patient's pattern of drug-taking that is characterized by behavioral and physiological responses, which may include:
- A compulsion to take the drug in order to experience its psychic effects, or to avoid the discomfort of its absence.
- An inability to stop the use of the drug despite strong incentives.
- Physical dependence (i.e., tolerance and withdrawal).
When documenting substance use disorders, include the following:
- Severity — Mild, moderate, etc.
- Pattern of use — Continuous use, in remission, relapsed, etc.
- Substance-induced mood/psychotic symptoms — Depression, hallucinations, anxiety, etc.
- Current presentation — Intoxication, drunkenness, withdrawal
- Treatment plan — Rehabilitation, maintenance therapy (specify drug), AA, etc.
Drug dependence in context of appropriate medical treatment — Physical dependence (i.e., tolerance and withdrawal) can develop with the chronic use of many drugs. This can include prescription drugs, even if taken as instructed. ICD-10-CM does not distinguish between this normal, expected response and other forms of drug dependence. Any type of drug dependency (i.e., prescribed, non-prescribed [illicit], physiological and/or behavioral) is coded similarly.
The “substance use disorders” of DSM-5 are reported in ICD-10 as follows:
Substance use disorder, mild
Substance use disorder, moderate
Substance use disorder, severe (addiction)
When use, abuse, and dependence of the same substance are documented in the encounter note, only one code should be assigned based on the following hierarchy:
Both use and abuse are documented
Both abuse and dependence are documented
Use, abuse, and dependence are documented
Both use and dependence are documented
ICD-10-CM Code Selection
The presence of a condition can’t be assumed, even if evidence is present in the medical record. It requires the provider’s clinical judgment and explicitly stated diagnosis. The diagnosis code reported must match the documented diagnosis assessed by the provider.
Identify the substance:
- Alcohol (F10)
- Stimulant (F15) (non-cocaine)
- Opioid (F11)
- Hallucinogen (F16)
- Cannabis (F12)
- Nicotine (F17)
- Sedative/Hypnotic/Anxiolytic (F13)
- Inhalant (F18)
- Cocaine (F14)
- Other Psychoactive Substance (F19)
The severity is determined by the number of symptoms present in the individual.
- Mild — 2-3
- Moderate — 4-5
- Severe — 6 or more
- In remission — Remission occurs when none of the criteria for substance use disorder (except craving) for at least three months.
- Early remission: more than three to less than 12 months
- Sustained remission: more than 12 months
Further specify any applicable detail:
- Environment or method of achieved remission
- “In a controlled environment” — When the individual in remission is in a supervised residential setting where access to alcohol and controlled substances is restricted
- “On maintenance therapy” — When the individual in remission is being maintained on a prescribed medication (e.g., agonist, partial agonist, agonist/antagonist, or full antagonist)
- Association with intoxication or withdraw
- Presence of induced manifestation or complication
- Perceptual disturbance
- Sexual dysfunction
- Sleep or mood disorder
- Persisting amnestic disorder or dementia
- Detailed clinical diagnosis and treatment plan/condition management
 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.
 ICD-10-CM Categories F10-F19 have been expanded to include substance and alcohol use in remission effective October 1, 2023. FY2023 official coding guidelines and descriptions can be found at https://www.cms.gov/medicare/icd-10/2023-icd-10-cm
AMB21-AR-H-146 Updated on November 16, 2021
A Cerebrovascular accident (CVA), also known as a stroke, occurs when there is an interruption to blood flow that supplies oxygen to the brain. There are two different types of strokes:
- Ischemic Stroke — Blockage of blood vessel in the brain due to a blood clot or stenosis.
- Hemorrhagic Stroke — Bleeding into the brain caused by a broken blood vessel.
A stroke is an emergent event that requires treatment in an acute care setting.
Residual or late effects (sequelae) caused by a stroke may be present from the onset of a stroke or arise at ANY time after the onset of the stroke. Some conditions develop slowly and exist over extended periods. Others develop suddenly and last only a few days or weeks.
A transient ischemic attack (TIA) is a temporary episode of neurologic dysfunction caused by ischemia without acute infarction. It is sometimes referred to as a mini stroke because the symptoms are similar to that of a stroke. The symptoms can resolve within minutes, or can last up to 24 hours.
Detailed documentation is necessary for proper code selection:
- Specify the location or source of hemorrhage and its laterality.
- Specify the source of occlusion and the vessel affected.
- If applicable, identify the specific neurologic or cognitive deficit, identify the affected extremity and laterality and whether it is the dominant or non-dominate side, and specify the type of event as the causing of the sequelae.
- Stenosis — narrowing
- Occlusion — complete or partial obstruction
- Thrombosis — stationary blood clot lodged in vessel
- Embolism — blood or other clot carried through vessel
- Meninges — protective membranes surrounding the cerebral cortex (brain)
- Dura matter (outer), Arachnoid (middle), Pia matter (inner)
- Epidural — between dura matter and skull
- Subdural — between dura matter and arachnoid
- Subarachnoid — between arachnoid and pia matter
- Precerebral arteries — vertebral, basilar, carotid
- Cerebral arteries — anterior, middle, and posterior
Assign the most specific code as appropriate according to documentation. More than one code may be assigned if specific code is available for separate locations. Watch for parenthetical notes found in the tabular list (e.g., excluded conditions, coding sequence, etc.).
Acute conditions must only be reported when present and actively being treated. Chronic conditions should be reported when treatment is required and/or affects care. Once a condition has resolved, it should no longer be reported as active.
- Category I60 — I62: Non-traumatic cerebral hemorrhage
- Category I63: Cerebral Infarction
- Category I65 — I68: Other cerebrovascular disorders and diseases
- Category I69: Sequelae of cerebrovascular disease
Acute conditions found in Category I60-I67 are applicable to the initial event.
After discharge from acute care, the condition is classified by:
- Sequela (late effects) found in Category I69.
- Personal history of CVA or TIA without residual deficits, Z86.73.
- Transient cerebral ischemic attack, G45.9 should be reported at the time of initial diagnosis. Refer to personal history of TIA and CVA without residual deficits, Z86.73 for subsequent encounters.
- See Category S06 for Intracranial hemorrhage due to accident or injury (traumatic).
- See Category I97 & G97 for guidance on intraoperative and postoperative events. Causal relationships must be clearly documented.
- Use Additional code to identify presence of:
- Alcohol abuse and dependence (F10.-)
- Exposure to environmental tobacco smoke (Z77.22)
- History of tobacco dependence (Z87.891)
- Hypertension (I10-I16 )
- Occupational exposure to environmental tobacco smoke (Z57.31)
- Tobacco dependence (F17.-)
- Tobacco use (Z72.0)
NOTE: The information listed here is not all inclusive and is to be used as a reference only. Please refer to applicable coding and documentation resources for the current year.
Peripheral vascular disease (PVD) describes any disorder of the blood vessels outside the heart and chest or disorders that affect blood flow through the arteries and/or veins.
Peripheral vascular disease (PVD) is also known as:
- Peripheral artery disease (PAD)
- Peripheral arterial insufficiency
- (Intermittent) Claudication
- Peripheral angiopathy
- Spasm of artery
ICD-10-CM code I73.9 — Peripheral vascular disease, unspecified is assigned for all conditions listed above when documented in the medical record.
Arteriosclerosis is the hardening of the arteries. Atherosclerosis is a pattern of arteriosclerosis in which the artery narrows due to the buildup of plaque (fatty deposits) inside the artery the wall.
These conditions are applicable to ICD-10-CM Category I70:
- Arteriosclerotic vascular disease
- Arteriovascular degeneration
- Endarteritis deformans or obliterans
- Senile arteritis
- Senile endarteritis
- Vascular degeneration
PVD due to atherosclerosis should be documented, if applicable, to correctly assign codes with higher specificity. Note: Atherosclerosis of extremities; unspecified refers to type, not location.
Signs and Symptoms
- Claudication — Foot, calf, buttock, hip or thigh pain or discomfort when walking that is relieved by rest.
- Cyanosis — Bluish discoloration of the skin resulting from poor circulation.
- Femoral or Carotid bruit - vascular murmur sound heard over a partially occluded blood vessel on auscultation.
- Slow healing wound or skin infection
- Slow capillary refill
- Numb/painful sensations in extremities
- Atrophic skin changes
- Decreased nail growth
- Abnormal or diminished pedal pulses
- Non-pressure ulcer
- Toes or feet appear pale or discolored
- Ischemic rest pain
Abnormal physical exam findings must be confirmed with diagnostic testing.
- Ankle brachial index (ABI)
- CT angiogram (CTA)
- Doppler ultrasound
Other vascular diseases:
- Deep vein thrombosis
- Varicose veins
- Chronic venous insufficiency
- Critical, limb-threatening ischemia
Complications and Interventions
Early interventions can the lower the risk of complications.
- Limited mobility
- Heart attack
- Healthy diet
- Regular exercise
- Lose weight
- Quit smoking
- Thrombolysis (CDT)
Coding and Documentation
Include the following details in the medical record:
- Cause (e.g., atherosclerosis, stenosis)
- Location of vein/artery affected (leg, foot, heal, ankle, calf, thigh)
- Laterality — specify left, right or bilateral
- Status of the artery (e.g., native, bypass graft, autologous, non-autologous biological)
- Complications such as rest pain, intermittent claudication, ulceration (document ulcer site) or gangrene.
Document diagnostic test results and any clinical findings that support PVD along with disease status and treatment plan.
Also include the following details, when applicable:
- Risk factors (e.g., tobacco use, high cholesterol, morbid obesity)
- Counseling provided to patient (e.g., smoking cessation)
- Co-morbidities such as HTN, DM, and CAD with disease status and treatment plan.
 Everett Stephens, MD. Peripheral Vascular Disease Guidelines. [Updated 2017 Dec. 31]. In: Medscape [Internet]. 1994–2020 by WebMD LLC. Peripheral Vascular Disease Guidelines
 Smith DA, Lillie CJ. Arterial Occlusion, Acute. [Updated 2020 Apr. 23]. In: StatPearls [Internet]. Treasure Island (FL): Stat Pearls Publishing; 2020 Jan. Acute Arterial Occlusion. Attribution 4.0 International (CC BY 4.0)
Hepatitis means inflammation of the liver. Toxins, certain drugs, some diseases, heavy alcohol use, bacterial or viral infections can cause hepatitis. Hepatitis is also the name of a family of viral infections that affect the liver.
Viral Hepatitis Types
Acute viral hepatitis generally resolves within a few months from the date of onset. In other cases, the disease becomes a long-term or chronic illness.
Chronic hepatitis is classified as inflammation caused by viral hepatitis lasting longer than six months. If left untreated, chronic hepatitis can cause serious health problems, including liver damage, cirrhosis, liver cancer, and even death
- Hepatitis A — Caused by ingesting contaminated water or food. Highly contagious, can also be contracted from close contact with an infected person or object.
- Hepatitis B — Spread through bodily fluids during sexual contact or through blood transfusions
- Hepatitis C — Blood-borne, spread through direct contact with infected blood. Primarily transmitted by needles shared among drug abusers, blood transfusion, hemodialysis and needle sticks, can also be transmitted by sexual contact
- Hepatitis D — Also known as delta, cannot occur in the absence of Hepatitis B. Hepatitis B with delta agent is the most severe form of (acute and chronic) hepatitis
- Hepatitis E — Acute condition caused by ingesting contaminated food or water, which does not lead to chronic hepatitis
The most common types are Hepatitis A, Hepatitis B, and Hepatitis C. Hepatitis A and E are acute in nature and do not lead to chronic hepatitis. Hepatitis B, C, and D viruses can cause chronic, sometimes lifelong conditions.
Signs and Symptoms
Signs and symptoms of viral hepatitis may or may not be present. Only lab tests can confirm which viral agent is present. Symptoms can include:
- Loss of Appetite
- Abdominal pain
- Dry mucous membranes
- Hepato-jugular reflex
- Firm/enlarged liver
- Palmar erythema
Hepatitis A (HAV)
- Hepatitis A surface antibody (HAV IgM) test detects the first antibody produced by the body when it is exposed to Hepatitis A. It detects early or recent infections and diagnoses the disease in people with symptoms of acute hepatitis.
Hepatitis B (HBV)
- Hepatitis B surface antigen (HBsAg) is present in acute and chronic infection.
- Anti-Hepatitis B core antigen (Anti-HBc IgM) is only positive during the acute phase of the infections.
Hepatitis C (HCV)
- There is no acute infectious phase serological testing available.
- Confirmation of infection determined by Anti-Hepatitis C (Anti-HCV) for initial screening, which can be confirmed with more specific testing through polymerase chain reaction (PCR) and/or nucleic acid testing (NAT).
HCV Screening &Test Results
HCV Antibody Test:
Non-reactive/Negative, HCV not present
Never had HCV
Recent HCV infection
- 2–9 mos. to produce antibodies
Weak immune system
- Unable to produce antibodies
Reactive/Positive, HCV present (need add’l test)
- Possible current HCV infection
- History of HCV
- Virus cleared naturally
- Virus medically treated/cured
HCV RNA Viral Load Test:
Undetectable, No HCV found in bloodstream
- Spontaneously cleared
- Medically cured
- Recently infected, less than two weeks
- Within lower limit of detection (LLOD)
- vVaries, can be as low as <5 IU/mL
Detectable < LLOQ, HCV present in bloodstream less than lower limit of quantification (LLOQ)
- Amount too small to measure
- HCV present in bloodstream
Other Chronic Hepatitis and Related Conditions
- Autoimmune hepatitis — Caused by the body’s own immune system attacking hepatic cells of the liver, typicClly due to genetic predisposition or environmental exposure.
- Lobular Hepatitis — Affects one or more of the four lobes (caudate, quadrate, left, right) of the liver.
- Hepatomegaly — Enlarged liver
- Hepatic fibrosis — Chronic injury or inflammation causes a buildup of scar tissue.
- Hepatic cirrhosis — Late stage of hepatic fibrosis with changes to the organ structure. —Caused by many liver diseases and conditions, such as hepatitis and chronic alcoholism.
- Hepatocellular carcinoma — Most common form of liver cancer, which is caused either by genetic predisposition, hepatitis, or underlying cirrhosis.
Coding and Documentation
Detailed documentation is necessary for proper code selection.
- Identify the type of hepatitis
- Indicate the acuity — Chronic, acute, with/without hepatic coma, with/without delta agent
- If viral hepatitis is not specified as acute or chronic, assign the appropriate code for unspecified viral hepatitis from Category B19.
- Viral hepatitis in remission, any type, code to Hepatitis chronic, by type.
- For patients who have had a liver transplant, document and report the appropriate transplant status code and document any anti-rejection drugs if appropriate.
- Specify the causal agent or behavior that led to the acquisition of hepatitis.
- Refrain from using the term “History of” if a patient still has an active viral infection.
- Document treatment and follow up.
ICD-10-CM Code Selection
Chronic hepatitis NEC:
(See Category K73)
(See Category K70 – K72, K76)
- Acute, chronic, alcoholic, unspecified
- Portal hypertension
- Hepatorenal syndrome
- Hepatopulmonary syndrome
(See Categories K70, K74)
- Primary/secondary biliary
- Alcoholic with/without ascites
- Auto-immune hepatitis (K75.4)
- Jaundice (R17)
- Malignant neoplasm of liver (C22-)
- Alcoholic liver disease (K70.9)
- High risk sexual behavior (Z72-)
 Hepatitis D
 Hepatitis C Virus (HCV) Diagnostics (PDF)
AMB21-AR-H-145 Updated on November 15, 2021
Ambetter Coding Tip Sheets And Forms
- 2022 HEDIS Quick Reference Guide (PDF)
- Ambetter Appropriate Treatment for URI (PDF)
- Ambetter Assess, Educate, and Treat Patients with Depression (PDF)
- Ambetter CAHPS HOS Survey Best Practices (PDF)
- Ambetter Child & Adolescent Immunizations (PDF)
- Ambetter Colorectal Cancer Coding/HEDIS (PDF)
- Ambetter CPT Category II Codes (PDF)
- Ambetter Entering Diagnosis Pointers on the Claim Form (PDF)
- Ambetter LBP and AAB (PDF)
- Ambetter Lower Back Pain Tip Sheet (PDF)
- Ambetter Marketplace Quality Quick Reference Guide (PDF)
- Ambetter Medications for Opioid Use Disorder (MOUD) (PDF)
- Ambetter Medications for Opioid Use Disorder (MOUD) — Buprenorphine (PDF)
- Ambetter Opioid Overdose Prevention (PDF)
- Ambetter Pharmacotherapy for Opioid Use Disorder (POD) (PDF)
- Ambetter Prenatal and Postpartum Care Tip Sheet (PDF)
- Ambetter Preventative Guide (PDF)
- Ambetter Reducing the Stigma: Mental Illness (PDF)
- Ambetter Safer Prescribing for Pain Management and Opioids (PDF)
- Ambetter Substance-Related Use Disorder (PDF)
- Ambetter Telehealth and Virtual Services (PDF)
- Ambetter Well Child and Adolescent Visits (PDF)
- Ambetter Well Woman Coding Tip Sheet (PDF)