Coding Tip Corner – June 2026

Accurately documenting the patient’s overall health status is extremely important to providing best practice when caring for patients. Here are a few friendly reminders: 

• • Communication is key for the patient to receive the appropriate treatment promptly.  
  • Accurate documentation and coding specificity enable a care team to allow a smooth transition if the patient should require treatment from a multidisciplinary team.  
  • Inadequate or inappropriate coding can result in poor coordination of care.  
  • Remember, the coder can only code what you document!

Tips for Capturing the Overall Health Status

Always remember: If it’s not documented, it didn’t happen!  

The medical record must have a legible signature: name, date, and credentials. 

Be sure that the diagnoses being billed match the actual medical record documentation. 

Cancer is coded as an active malignancy when the patient is undergoing active treatment — such as chemotherapy, radiation, or hormone therapy — or when the cancer is present and requires management (e.g., waiting for treatment, refusing treatment, or palliative care). Active codes are used until the cancer is removed and treatment ends. Otherwise, cancer is coded as a history.  

If coding Diabetes with complications, make sure complications are noted.  

Depression requires three elements: 

1. 1. Episode Type (First Time versus Recurrent) 
   2. Severity Level 
      • Mild: self-care is intact 
      • Moderate: self-care is declining 
      • Severe: self-care is compromised  
   3. Specifiers (partial or full remission) or additional details: 
      • Partial remission 
      • Full remission 
      • Psychotic features 
      • Subtypes (e.g., postpartum) 

Laterality allows for a more specific code to be documented: 

• • Specify right, left, bilateral. 
  • Corresponding modifiers should be documented (RT, LT, 50). 
  • If a bilateral code exists, it should be used instead of billing right and left separately. 

Morbid Obesity 

• • The provider must document the specific diagnosis (e.g., “morbid obesity,” “severe obesity”) in the assessment. 
  • The current, specific BMI must be recorded in the medical record. 

Associated Comorbidities 

• • Patients with a BMI of 35–39.9, qualifying comorbidities that document “morbid” (or severe) obesity include high-risk conditions such as type 2 diabetes, hypertension, obstructive sleep apnea (OSA), dyslipidemia, cardiovascular disease, sleep apnea, degenerative arthritis of weight-bearing joints (CMS).

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Top Three Coding Errors, according to CMS

1. 1. Insufficient Documentation (Missing/Unsigned Notes) 
   2. Coding Specificity 
   3. Upcoding/Downcoding