Documentation and Coding Reference Cards

Listed below are guides to assist with documentation and coding according to CMS documentation standards and ICD-10-CM coding requirements. These are a listing of some of the commonly encountered conditions in the primary care setting but are 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

Arrhythmia

• Arrhythmia Documentation Reference Card
• Arrhythmia Coding Reference Card

Arthritis

• Arthritis Documentation Reference Card
• Arthritis Coding Reference Card

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

CHF

• CHF Documentation Reference Card
• CHF Coding Reference Card

Coagulopathy

• Coagulopathy Documentation Reference Card
• Coagulopathy Coding Reference Card

COPD

• COPD Documentation Reference Card
• COPD Coding Reference Card

CVA

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

Dementia

• Dementia Documentation Reference Card
• Dementia In Other Diseases Classified Elsewhere Coding Reference Card - Part 1
• Dementia In Other Diseases Classified Elsewhere Coding Reference Card - Part 2
• Unspecified Dementia Coding Reference Card
• Vascular Dementia Coding Reference Card

Diabetes

• Diabetes Documentation Reference Card
• Diabetes Complications Documentation Reference Card
• Diabetes Type 1 Coding Reference Card
• Diabetes Type 2 Coding Reference Card

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/Seizures

• Epilepsy/Seizure Disorder Documentation Reference Card
• Epilepsy/Seizure Disorder Coding Reference Card

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

Kidney Disease

• Kidney Disease Documentation Reference Card
• Kidney Disease Coding Reference Card

Major Depressive Disorder (MDD)

• MDD Documentation Reference Card
• MDD Coding Reference Card

Malnutrition

• Malnutrition Documentation Reference Card
• Malnutrition Coding Reference Card

Morbid Obesity

• BMI and Morbid Obesity Documentation Reference Card
• BMI and Morbid Obesity Coding Reference Card

Movement & Neuro Disorders

• Movement & Neuro Disorders Documentation Reference Card
• Movement & Neuro Disorders Coding Reference Card

Myocardial Infarction (MI)

• Myocardial Infarction Documentation Reference Card
• Myocardial Infarction Coding Reference Card

Peripheral Vascular Disease (PVD)

• PVD Documentation Reference Card
• PVD Coding Reference Card

Social Determinants of Health

• 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