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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)
Dialysis status
  • Current
  • History
  • Hemodialysis
  • Peritoneal dialysis
Chronic Kidney Disease (CKD) Associated diagnoses/conditions
  • Diabetes
  • ESRD
  • Heart failure
  • Hypertension
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
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
  • 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)
Underlying conditions
  • Hypertension
  • Chronic Kidney Disease (CKD)
  • Other cardiac conditions

ECN009671 (0823)