Bonnie Patterson | CPC, CPMA, CMRS, CMCS
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ICD-10-CM Guideline Notes

High-value reminders for sequencing, specificity, documentation integrity, and defensible diagnosis coding.

Audit-Focused Coding Reminders

Accurate diagnosis coding begins with the documented clinical picture. These original notes reinforce a disciplined review process without reproducing official code-set language.

Sequencing

Confirm the reason for the encounter and apply applicable instructional notes before finalizing code order.

Specificity

Capture the highest supported level of detail, including site, laterality, acuity, episode, and associated conditions.

Uncertain Diagnoses

Apply the rule appropriate to the care setting and avoid converting tentative language into a confirmed condition.

Signs and Symptoms

Determine whether symptoms remain reportable or are integral to a confirmed diagnosis documented for the encounter.

Instructional Notes

Review code-first, use-additional-code, excludes, and other tabular instructions before claim submission.

Documentation Integrity

Do not infer unsupported relationships, severity, laterality, or causal links from clinical indicators alone.

Educational-use notice: This independently developed resource is a review aid only. It does not replace the current ICD-10-CM code set, Official Guidelines for Coding and Reporting, payer policy, or organization-specific coding guidance.
THINK LIKE AN AUDITOR

Ask These Three Questions

Before finalizing diagnosis coding, confirm that the code selection is supported, appropriately sequenced, and consistent with the documented care setting.

1

Does the documentation support every element of the selected code?

2

Have sequencing instructions and applicable tabular notes been reviewed?

3

Is the diagnosis status appropriate for the documented care setting?