This page addresses follow-up questions and additional information pertinent to our webinar
ICD-10-CM Coding Essentials: Clarifying Common Areas of Confusion.

** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.

Q: A provider documents a chronic condition during an office visit and notes that it is stable. The provider reviews the patient’s current treatment plan and continues the existing medication regimen. Does this condition meet M.E.A.T. criteria for ICD-10-CM coding?
A: Yes. The condition meets M.E.A.T. criteria because the provider actively addressed it during the encounter.

M.E.A.T. stands for:​
Monitoring – reviewing signs, symptoms, test results, or disease status ​
Evaluating – assessing the condition, response to treatment, or progression ​
Assessing/Addressing – discussing, managing, or considering the condition in clinical decision-making ​
Treating – initiating, continuing, adjusting, or discontinuing treatment ​

In this scenario:​

The provider evaluated the condition by documenting its current status. ​

The provider treated the condition by continuing the existing treatment plan. ​

Because at least one of the M.E.A.T. elements is supported by documentation, the condition may be considered active and reportable for the encounter, subject to applicable coding guidelines and payer requirements.​

Q: A condition is documented in a patient’s medical record during a current encounter. How can a coder determine whether the condition should be coded as an active diagnosis or as a history of a condition under ICD-10-CM guidelines?
A: A condition should generally be coded as active when documentation indicates that it currently exists and is being monitored, evaluated, assessed, addressed, or treated during the encounter. Evidence may include discussion of the condition’s status, ongoing management, treatment plans, medication use, or clinical decision-making related to the condition.

A condition may be coded as history of when documentation indicates that the condition no longer exists, has resolved, or is no longer receiving active treatment, but remains clinically relevant to the patient’s care. History codes are used to capture past conditions that may affect current healthcare decisions, risk assessment, or follow-up care.

Q: When should a coder assign a combination code instead of reporting multiple ICD-10-CM codes separately?
A: A coder should assign a combination code when a single ICD-10-CM code fully identifies two or more diagnoses, a diagnosis with an associated manifestation, or a diagnosis with a related complication, as described in the Alphabetic Index or Tabular List.

Before assigning multiple codes, the coder should determine whether a combination code exists that captures all documented conditions. If the combination code completely describes the documented clinical scenario, it should be reported instead of separate codes, unless ICD-10-CM instructions require additional coding.

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