Coding Tip Corner – October 2026

In May of this year, the Centers for Medicare & Medicaid Services (CMS) announced a bold strategy to enhance and accelerate Risk Adjustment Data Validation (RADV) audits of Medicare contracts. While there is nothing that can be done to change previous documentation, you can improve documentation moving forward.

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What Actions Can Providers Take to Ensure Their Records Are Audit-Ready?

Accurate and specific documentation with each visit and strong collaboration between coders and providers are essential. Please consider the following at your practice:

• • Are you approachable if the coder has a question?
  • Do you set aside a few minutes a day or week to answer a coder’s question regarding clarification?
  • Is there a designated coder who gathers the questions daily or weekly and presents those to you?

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Common Coding Errors

Here are a few of the coding errors we are finding during the review of the 2025/2026 records:

• • Documentation states diabetes with complications, but no complications are documented.
  • Insufficient documentation: Failure to record key elements required to establish medical necessity.
  • Conflicting documentation: Conflicting information should never be documented during a visit. For example, the patient’s record documents both type 1 and type 2 diabetes during the same visit.
  • Cancer status: Cancer is either active or history. If it is current, be sure to include current treatment.

In most cases, your eyes are the last ones to view the patient’s visit. So if you see something that you know isn’t right, say something! Many providers rely on your expertise in capturing the correct codes for the visit. If a condition is not captured during the visit, you should not be capturing a code for it.

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Additional Coding Errors Identified During Audit Record Reviews

• • Myocardial infarction (MI): An MI is coded as a new MI long after the first 28 days.
  • Cerebrovascular accident (CVA), I63 vs. I69: A CVA should be documented and coded as acute only at the onset of the original encounter during which it is diagnosed, and the initial evaluation and treatment take place. This is in a hospital setting 99.9% of the time.

If you see a CVA being captured with an I63 code when a patient is being seen in the office as a follow-up, it should be a red flag! If there is sequela, this should be coded using a code from the I69 description.

If the patient has completely recovered and has no residual neurological deficits from a previous stroke, the appropriate code is Z86.73.

• • Hypertension and chronic kidney disease (CKD): If the patient has hypertension as well as CKD confirmed, the code is I12.9 rather than I10.

A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation, accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

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Important Coding Updates

Effective October 1, there are 190 new diagnosis codes, 4 revised descriptors, and 30 deleted or invalidated codes. The ICD-10 diagnosis codes fall under the six clinical specialties:

• • Cardiology
  • Hepatology
  • Musculoskeletal and Podiatry
  • Otolaryngology
  • Infectious Disease
  • Nutrition and Metabolic Systems

Visit the CMS website to learn more.