Documentation and Coding Reference Cards

Listed below are guides to assist with documentation and coding according to Centers for Medicare and Medicaid Services (CMS) documentation standards and ICD-10-CM coding requirements. These are some of the commonly encountered conditions in the primary care setting, but this is not an exhaustive list of every condition. Check back regularly as new conditions may be added based on current trends and coding guideline changes.

Amputation

• Amputation Documentation Reference Card
• Amputation Coding Reference Card

Angina

• Angina Documentation Reference Card
• Angina Coding Reference Card

Arrhythmias

• Arrhythmias Coding and Documentation Resource

Arthritis

• Rheumatoid Arthritis Coding and Documentation Resource

Artificial Openings (Ostomies)

• Artificial Openings Documentation Reference Card
• Artificial Openings Coding Reference Card

Asthma

• Asthma Documentation Reference Card
• Asthma Coding Reference Card

Atherosclerosis

• Atherosclerotic Heart Disease Documentation Reference Card
• Atherosclerosis of Extremities Documentation Reference Card
• Atherosclerosis Coding Reference Autologous Nonautologous Graft
• Atherosclerosis of Extremities Coding Reference Card - Part 1
• Atherosclerosis of Extremities Coding Reference Card - Part 2
• Atherosclerosis of Extremities Coding Reference Card - Part 3

Autoimmune Disorders

• Autoimmune Documentation Reference Card
• Autoimmune Coding Reference Card

Behavioral Disorders

• Behavioral Disorders Documentation Reference Card
• Behavioral Disorders Coding Reference Card

Cancer

• Cancer Documentation Reference Card
• Cancer Coding Reference Card

Cardiomyopathy and Heart Failure

• Cardiomyopathy and Heart Failure Coding and Documentation Resource

Chronic Kidney Disease (CKD)

• CKD Coding and Documentation Resource

Chronic Obstructive Pulmonary Disease (COPD)

• COPD Coding and Documentation Resource

Coagulopathy

• Coagulopathy Documentation Reference Card
• Coagulopathy Coding Reference Card

CVA

• CVA Documentation Reference Card
• CVA Coding Reference Card - Active
• CVA Coding Reference Card - Sequela

Dementia

• Dementia Coding and Documentation Resource

Diabetes

• Diabetes Coding and Documentation Resource
• Diabetic Retinopathy Coding and Documentation Resource

Embolism/Thrombosis/Phlebitis

• Embolism/Thrombosis Documentation Reference Card
• Embolism Lower Extremity ACUTE Coding Reference Card
• Embolism Lower Extremity CHRONIC Coding Reference Card
• Embolism/Thrombosis Lower Extremity Coding Reference Card
• Embolism/Thrombosis Torso Upper Extremity Coding Reference Card
• Phlebitis/Thrombophlebitis Coding Reference Card

Epilepsy and Seizures

• Epilepsy and Seizures Coding and Documentation Resource

Eye Disorders

• Exudative Macular Degeneration Coding and Documentation Resource
• Other Eye Diseases Coding and Documentation Resource

Hemolytic And Hemorrhagic Disorders

• Hemolytic and Hemorrhagic Documentation Reference Card
• Hemolytic and Hemorrhagic Coding Reference Card

Hepatitis

• Hepatitis Documentation Reference Card
• Hepatitis Coding Reference Card

Immunodeficiency

• Immunodeficiency Documentation Reference Card
• Immunodeficiency Coding Reference Card - Part 1
• Immunodeficiency Coding Reference Card - Part 2

Major Depressive Disorder (MDD)

• MDD Coding and Documentation Resource

Malnutrition

• Malnutrition Documentation Reference Card
• Malnutrition Coding Reference Card

Morbid Obesity

• Morbid Obesity Coding and Documentation Resource

Movement and Neurological Disorders

• Movement and Neurological Disorders Coding and Documentation Resource

Myocardial Infarction (MI)

• MI Documentation Reference Card
• MI Coding Reference Card

Peripheral Vascular Disease (PVD)

• PVD Documentation Reference Card
• PVD Coding Reference Card

Social Determinants of Health (SDOH)

• SDOH Coding Reference Card 1
• SDOH Coding Reference Card 2

Substance Use Disorders

• Substance Use Disorders Documentation Reference Card
• Substance Use Disorders Alcohol Coding Reference Card
• Substance Use Disorders Coding Reference Card

Ulcers

• Pressure Ulcers Documentation Reference Card
• Pressure Ulcers Coding Reference Card
• Non-Pressure Ulcers Coding Reference Card - Part 1
• Non-Pressure Ulcers Coding Reference Card - Part 2