Coding Tip Corner – February 2026

The Golden Rule of Medical Documentation

In 2026, let’s ensure all medical records will pass CMS standards for documentation! 

“If it isn’t documented, it didn’t happen,” emphasizes that records must be timely, accurate, complete, and objective to reflect actual patient care, justify services for billing, ensure continuity of care, and serve as legal proof, with the core principle being to prepare notes as close to the time of treatment as possible. 

This month’s newsletter is utilizing a little different approach to documenting. Here is a list of what to avoid documenting in the patient’s record: 

• Copy & Paste: This is frequently found in charts and is UNACCEPTABLE by all standards. 
• Opinions & Judgments: Patient is “noncompliant” 
• Excuses: “Medication not given because it was not available” 
• Uncommon Abbreviations: This can lead to misinterpretation (“MS” can be mag sulfate or Morphine, two entirely different medications)
• Anticipatory Charting: Documenting care before it is performed (considered fraud) 
• Irrelevant Data: Trivia or non-clinical information 
• Personal comments about the patient or colleagues: Derogatory, unprofessional, or non-medical personal remarks 
• Term “history of”: Is this a current or a resolved condition when found in the assessment? 

Office Staff Reminders

Please be sure to adhere to the following on a patient’s medical record: 

• Full first name on the record not just an initial (i.e., J.) 
• First name “Johnny” but name listed as John 
• If the name is Randell, this should be on the record as such and if member prefers to be called “Randy”, this can be listed alongside on the record 
• Legal name should match the insurance card; PREFERRED name can be listed on the same line on the record i.e., Wanda, Winnie 
• Please double-check that the full date of birth is correct. On occasion, it has been found to be a year off either way.  
• Completely wrong name attached to correct date of birth 
• Do not reverse name by using patients’ middle name as their first name i.e., name James D. (David appears as the name on the record), James D. on card 
• If it is a hyphenated Smith-Jones, the record should reflect this, not just Smith or Jones 
• Completely different name on front sheet (Gayle) and “Sylvia” is on the record with a matching date of birth, not acceptable 

If the member prefers to be addressed by a different name than what is on the insurance card, please document the name on the front sheet as well, otherwise the record will not be accepted by CMS for review! 

Diabetes Code Change

Just a friendly reminder that effective October 1, 2025, the main ICD-10-CM diabetes change is the introduction of a new code E11.A, for Type 2 Diabetes Mellitus without complication in remission, allowing providers to code for successful management where normal blood glucose is maintained without medications or complications, emphasizing that “remission” isn’t the same as “cure” or resolved. Coders are required to ensure the provider documentation clearly states remission and no complications to use E11.A, as it doesn’t cover cases with associated conditions. 

Documentation needed for coding E11.A: Providers must clearly document the diabetes is in REMISSION, specify current HbA1c levels, mention lifestyle interventions, and confirm the absence of diabetes medications and ongoing complications. 

Remission is considered when the patient maintains normal blood glucose levels (often defined as HbA1c < 6.5% for 3 plus months) without requiring diabetes medications.