Commercial Risk Adjustment (CRA) ICD-10-CM Clinical Documentation Improvement for Chronic Conditions

Clinical Documentation Improvement assists physicians with accurate and complete documentation to better reflect a patient's clinical status. This information will assist physicians in accurately and thoroughly capturing the level of disease severity and supporting the Management, Evaluation, Assessment and Treatment of the active chronic and co-exiting conditions. Documentation in the medical record must fully support the coding assignment of a condition.

Chronic Condition	Documentation Category	ICD-10-CM Clinical Documentation Improvement Guidelines
Neoplasms	Type	Malignant primary (first site) Malignant secondary (metastatic site) Carcinoma in situ (pre-invasive cancer) Benign (non-cancer) Uncertain behavior (diagnosis made by pathologist; morphology of tumor uncertain) Unspecified (pathology unknown)
	Laterality	Left Right Quadrant For paired organs or extremities
	Anatomical site	Location (lung and right bronchus, ascending colon, etc., be specific) Overlapping sites
	Complications associated with neoplasm	Dehydration, anemia, pathologic fractures, etc.
	Estrogen receptor status	If applicable
	History of	Has malignancy been excised or eradicated? Yes Is treatment being administered to primary and/or metastatic site? No Is there evidence of malignancy at primary site? No
Diabetes	Type	Type 1 or Type 2 Drug/chemical induced Due to underlying condition Other specified type
	Control	Inadequate control Out of control Poorly controlled Hypoglycemia Hyperglycemia
	Treatment	If applicable, document long-term use of insulin (Type 2 only)
	Manifestations/Complications (Document causal relationship) See ICD-10-CM Index: Diabetes, “With” for an exhaustive list	Circulatory complications Hyperosmolarity (with or without coma) Hypoglycemia (with or without coma) Ketoacidosis (with or without coma) Kidney complications (e.g. CKD) Neurological complications Ophthalmic complications Oral complications Skin complications Circulatory complications Arthropathy Other specified complications
Asthma	Severity	Mild Intermittent, with exacerbation (acute) status asthmaticus Symptoms 2x per week or less Twice a month or less of nighttime waking symptoms Necessary relief by inhaler 2x per week Little or no interference with activities Normal peak flow between symptoms Not requiring oral steroids to control or requiring once per year Mild Persistent, with exacerbation (acute) status asthmaticus Symptoms more than 2x per week, but not every day Three to four times per month of waking night symptoms Necessary relief by inhaler more than 2x per week Minor interference with activities Peak flow equal to 80 percent of personal norm Requiring oral steroids 2x per year Moderate Persistent, with exacerbation (acute) status asthmaticus Daily symptoms Waking night symptoms more than 1x per week Necessary relief by inhaler daily Sometimes interference with activities Peak flow equal of 60 to 80 percent of personal norm between symptoms Requiring oral steroids 2x per year Severe Persistent, with exacerbation (acute) status asthmaticus Frequent symptoms throughout the day Waking night symptoms often every night Necessary relief by inhaler several times per day Severely limits daily activities Peak flow less than 60 percent of personal norm between symptoms Requiring oral steroids 2x or more per year
	Type	Cough variant Exercised-induced bronchospasm Childhood Extrinsic allergic Intrinsic non-allergic Idiosyncratic Late onset Mixed Other (specify)
	Associated diagnoses/conditions	Exposure to environmental tobacco smoke History of tobacco use Occupational exposure to tobacco smoke Tobacco dependence Tobacco use
Chronic Kidney Disease (CKD)	Stage	CKD, Stage 1 (GFR ≥ 90) CKD, Stage 2 (Mild)/(GFR 60-89) CKD, Stage 3 (Moderate)/(GFR 45-59), 3a CKD, Stage 3 (Moderate)/(GFR 30-44), 3b CKD, Stage 4 (Severe)/(GFR 15-29) CKD, Stage 5 (GFR less than 15 or on dialysis) End-Stage Renal Disease (ESRD) (Renal replacement therapy, dialysis or transplant) Glomerular Filtration Rate (GFR)
Chronic Kidney Disease (CKD)	Dialysis status	Current History Hemodialysis Peritoneal dialysis
Chronic Kidney Disease (CKD)	Associated diagnoses/conditions	Diabetes ESRD Heart failure Hypertension
Chronic Kidney Disease (CKD)	Transplant status	If applicable
Rheumatoid Arthritis	Laterality	Left Right
	Site	Shoulder Elbow Wrist Hand Hip Knee Ankle and foot Vertebrae Multiple sites
	Specify	With rheumatoid factor Without rheumatoid factor With involvement of other organs and systems Without involvement of other organs and systems
	Manifestations	Bursitis Myopathy Nodule Polyneuropathy Other organ or system involved (e.g., lung, pericardium)
Behavioral Health
Mood Disorders	Type	Maniac episode Organic Persistent Bipolar episode Major Depressive Disorder Single episode Recurrent episode Other (specify)
	Severity	Mild Moderate Severe
	Remission status	Partial remission Full remission
	Associated manifestations	With psychotic features Without psychotic features
Bipolar Disorder	Type	Hypomanic Manic with psychotic features Manic severe without psychotic features Mixed Depressed
	Severity	Mild Moderate Severe Unspecified
	Episode of Care	Single episode In remission Full Partial Unspecified
Substance Abuse	Type of abuse	Substance Nicotine Alcohol Cocaine Opioids Hallucinogens
	Type of use	Use (e.g., had drink/cigarette today) Dependence (addiction) Abuse (occasional drug user/binge drinker)
	Status	In remission With intoxication Uncomplicated With delirium With withdrawal Uncomplicated With delirium Personal history of Substance Abuse
	Associated behaviors	Anxiety Hallucinations Psychotic disorders Sleep disorder Sexual dysfunction
	Treatment	Detoxification services Counseling Psychotherapy Medication management Pharmacotherapy
Poisoning	Type	Name of drug/chemical
	Associated conditions	Specify all manifestations
	Intent	Accidental Self-harm Assault Investigated but undetermined
	Encounter	Initial Subsequent Sequela
	Poisoning due to	Overdose Wrong dose given/taken in error Wrong route of administration
Pervasive Developmental Disorders	Type	Autistic disorder Infantile autism Infantile psychosis Kanner’s syndrome Rett syndrome Other childhood disintegrative disorder Dementia infantilis Disintegrative psychosis Heller’s syndrome Symbiotic psychosis Asperger’s syndrome Asperger’s disorder Autistic psychopathy Schizoid disorder of childhood Other pervasive developmental disorders Pervasive developmental disorder, unspecified Atypical autism
Pervasive Developmental Disorders	Associated diagnoses/conditions	Associated medical conditions Intellectual disabilities Associated neurological conditions
Cardiology
Atrial Fibrillation	Type	Paroxysmal Episodes come and go, but resolve on their own Persistent Episodes that require intervention (medication, cardioversion, ablation) to stop the atrial fibrillation and return heart to normal sinus rhythm (NSR) Permanent (chronic) Permanent atrial fibrillation, present all the time and cannot be returned to NSR with intervention Unspecified No documentation of the specificity of the atrial fibrillation
Atrial Flutter	Type	Typical – Type I Atypical – Type II If fibrillation and flutter rhythm, code both
Paroxysmal Tachycardia	Type	Re-entry ventricular arrhythmia Supraventricular tachycardia Ventricular tachycardia Unspecified
Other Types of Arrhythmias	Type	Ventricular fibrillation or flutter Atrial premature depolarization Junctional premature depolarization Ventricular premature depolarization Sick sinus syndrome
Other Types of Arrhythmias	Long-term use of anticoagulant	If applicable
Congestive Heart Failure (CHF)	Type	Left ventricular failure Systolic Acute Chronic Acute on Chronic Unspecified Diastolic Acute Chronic Acute on Chronic Unspecified Combined systolic/diastolic Acute Chronic Acute on Chronic Unspecified Heart failure, unspecified Biventricular failure Not Otherwise Specified (NOS) Cardiac, heart or myocardial failure NOS Congestive heart disease Congestive heart failure, unspecified Right ventricular failure (secondary to left hear failure)
Congestive Heart Failure (CHF)	Underlying conditions	Hypertension Chronic Kidney Disease (CKD) Other cardiac conditions

ECN009671 (0823)