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 |
|
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)
|
Dialysis status |
- Current
- History
- Hemodialysis
- Peritoneal dialysis
|
Chronic Kidney Disease (CKD) |
Associated diagnoses/conditions |
- Diabetes
- ESRD
- Heart failure
- Hypertension
|
Transplant status |
|
Rheumatoid Arthritis |
Laterality |
|
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 |
|
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
|
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 |
|
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
|
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
|
Long-term use of anticoagulant |
|
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)
|
Underlying conditions |
- Hypertension
- Chronic Kidney Disease (CKD)
- Other cardiac conditions
|