Coding Tip Corner – January 2026

Happy New Year! Here are few reminders about what must be captured in the medical record.

The elements below often have been missed in records that have been randomly reviewed. We are not telling you how to code; we are asking that you code to the highest level of specificity. This may sound redundant, but it is worth repeating for 2026!

• Supporting documentation must go with all current / chronic conditions. These conditions must be reviewed at least annually, and supporting documentation must be noted annually as well.
• NEVER COPY and PASTE. This is unacceptable.
• History vs. current. This is often found with a cancer diagnosis. Are they currently receiving treatment? Supporting documentation required can include:

1. 1. Chemo / Medications
   2. Radiation
   3. Monitoring
   4. Treatment refused
   5. Documentation that shows the cancer is being actively managed

• Coding diabetes on a patient with CKD as well. Is this E11.9, or is there an attributed manifestation of the patient’s diabetes?
• CKD is mentioned in history, and staging is missing.
• Depression should be documented as to type, and treatment specificity is key in documentation:

1. 1. Episode type (single/recurrent)
   2. Severity (mild, moderate, severe, and with or without psychosis)
   3. Functional impact, treatment response
   4. Use of standardized tools

We often see depression not being specified, and no follow-through with treatment.

• Current conditions are placed in the PMH or Problem list.
• Social Determinants of Health (SDOH) are not completed, and often, if an issue is mentioned, no follow-through is noted.
• Final request: If the member goes by a different name than what is listed on their insurance card or medical record, please be sure that name also appears on the record, i.e., member name Doreen, but prefers to be called “Dolly”; both names need to be linked for identification purposes when the record is reviewed.

As Sir William Osler once said, “The good physician treats the disease, the great physician treats the patient who has the disease.”

We are fortunate to have many great physicians!

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More Coding Tips

As a medical coder in a provider’s office, you are faced with challenges daily. How you handle those challenges has the potential to make or break your day.

Never ignore Documentation or Specificity:

1. Primarily, if it is not documented, it did not happen
2. Distinguish between history and current conditions
3. Maintain effective communication with your providers
4. Remain current with coding standards and compliance regulations
5. It may be up to you to keep your providers up to date on coding changes
6. It may be beneficial to set time aside on a monthly or quarterly basis to meet with the providers to bring changes or focus on a recurring coding question

As a medical coder, you are acting as the link between patient care and healthcare revenue. If you see something, say something!