Health status condition documentation requirements
Certain ICD-9 codes are designated as status codes to identify that a patient is the carrier of a disease with:
- No current symptoms, or
- Lingering effects of a past condition or past treatment
Identifying the patient's health status may affect treatment or outcome of another condition.
Requirements
Providers must document and (when applicable) report on the patient's condition or status at least once per calendar year.
| Examples of ICD-9 Health Status Code Use |
| Condition/Status |
ICD-9 Health Status Code |
| Protein calorie malnutrition |
263.X |
Alcohol dependence syndrome
Drug dependence |
303.XX or 304.XX |
| Old myocardial infarction (MI) |
412 |
| Asymptomatic for HIV infection |
V08 |
| Organ or tissue replaced by transplant |
V42.X or V42.XX |
| Artificial opening (tracheostomy, gastrostomy, colostomy, ileostomy) |
V44.X |
| Renal dialysis |
V45.1X |
| Dependence on respirator |
V46.1X |
| Lower limb amputation |
V49.7X |
| Attention to artificial openings |
V55.X |
| Long-term (current) insulin use |
V58.67 |
