Health status condition documentation requirements

Certain 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