Coding Tip Corner – April 2026

Finding and documenting chronic conditions early in the year is the foundation for effective patient care and risk adjustment. Chronic conditions must be captured on an annual basis. This means they must be documented in the record as being monitored, evaluated, assessed, and treated at least once a year for all chronic conditions. They cannot simply be documented in the past medical history or problem list. 

10 Tips for Capturing Chronic Conditions

1. All pertinent information should be included in the provider’s progress notes. Report everything from the office visit that affects the plan of care for the chronic condition. 
2. Chronic conditions must be coded annually with the highest level of specificity. 
3. Patients must be evaluated by a medical doctor, a DO, a nurse practitioner, or an advanced practice provider during a face-to-face visit. 
4. All chronic conditions should be discussed and documented when meeting with a new patient. 
5. If the condition does not affect the patient’s care six months from the initial visit, there is no need to report it again. 
6. Document only confirmed diagnoses, not suspected conditions. 
7. Do not cut and paste the patient’s problem list and transfer it into the progress notes.  
8. Providers must link the chronic condition with the care plan by monitoring, evaluating, assessing, or treating the condition in some way, documenting care they provided or plan to provide. 
9. If chronic conditions are not linked to the care plan and a data validation audit occurs, the code will be removed and not counted as part of the patient’s risk adjustment factor. 
10. Progress notes must be signed by the provider for chronic conditions to count for an office visit.  

Coding Reminders

• Coding should be captured to the highest level of specificity. This involves selecting codes that are as detailed as possible based on documentation, avoiding “unspecified” codes when more specific information is available. Lack of specificity in ICD-10 Diagnosis codes is one of the top ten common denial reasons in 2026. 

Example: A note was coded as E11.8 with E78.5. The note specifically said the lipids were complications related to diabetes, so the more specific codes would have been E11.69 and E78.5.  

• Coding for laterality requires naming if a condition or procedure involves the left, right, or both sides to ensure correct ICD-10-CM diagnosis and CPT/HCPCS procedure reporting. Specific codes, such as those showing bilateral or proper modifiers (-RT, -LT.-50), are essential to avoid claim denials for lack of specificity. 

A code can be captured only to the specificity that it has been documented, so please take the extra minute to document to specificity of the condition as well as laterality if that is the case! If you have a question, query the provider to encourage accuracy in documentation.