I36

Clinical notes

Documentation support

General coding-documentation guidance — not a substitute for payer-specific requirements or professional coding judgment.

• •This is a non-billable header code. Documentation must support a more specific child code before this diagnosis can be reported on a claim.
• •Laterality-specific codes exist for this condition — confirm the affected side is documented.
• •Confirm the excluded condition(s) listed above are not also present — Excludes1 conditions cannot be coded together with this one.
• •As a general rule, code to the highest level of specificity supported by the documentation in the medical record.