Accurate ICD-10-CM coding in long term care (LTC) is not just a compliance exercise. It directly affects care planning, quality reporting, and reimbursement. Yet many facilities continue to struggle with recurring coding errors. Unlike acute care, the LTC environment involves prolonged stays and multiple chronic conditions. These realities make accurate diagnosis coding more challenging and critical. Diagnoses must be continuously reassessed and coded accurately to reflect current clinical management rather than admission-only or historical conditions.

The most common ICD-10-CM missteps in LTC are not usually the result of a lack of effort, but rather are due to documentation gaps, outdated habits, or misunderstandings of coding conventions and guidelines. Recognizing these patterns is the first step toward correcting them.

1. Failure to Reassess Diagnoses Over Time

Perhaps the most LTC-specific coding challenge lies in failing to reassess diagnoses as a resident’s condition evolves. Diagnoses appropriate at admission may no longer apply months later or new conditions may emerge. Postoperative aftercare codes, resolved infections, or temporary conditions should not remain on the diagnosis list indefinitely. Coordination with the physician or nonphysician practitioner (NPP) is essential to ensure that diagnosis lists are current. 

2. Overreliance on Unspecified Codes

A frequent issue in LTC coding is continuing to use unspecified diagnosis codes when greater specificity is available (or should be). ICD-10-CM allows unspecified codes, but only when the medical record truly lacks the information needed to assign a more specific code. In LTC, residents are assessed repeatedly, and their conditions are monitored over time. For example, continued use of unspecified codes for dementia, chronic kidney disease (CKD), or diabetes often reflects incomplete documentation rather than clinical uncertainty. Facilities can rectify this issue by encouraging physician/NPP documentation on diagnosis to be as specific as possible (e.g., severity, stage, associated conditions or complications). Coders should also feel free to query the physician when documentation is vague, rather than defaulting to unspecified options.

3. Omitting Active Conditions

Another common misstep is failing to code all actively managed conditions. ICD-10-CM requires reporting diagnoses that affect resident care, including those that require monitoring, evaluation, treatment, or nursing interventions. Chronic conditions such as diabetes, heart failure, chronic obstructive pulmonary disease (COPD), or depression are sometimes omitted because they are considered “baseline” for the resident. However, if these conditions influence care planning, medication management, or monitoring, they should be reported. At the same time, facilities must avoid the opposite problem: continuing to code conditions that are no longer active or clinically relevant. Accurate coding requires a thoughtful review of the entire medical record, not just copying forward a longstanding problem list. 

4. Misuse of History Codes

Personal history codes are often misapplied in nursing facilities, particularly for cancer and cerebrovascular accidents (CVAs). History codes should be used only when a condition is fully resolved and no longer requires treatment or monitoring. Residents with residual deficits or ongoing management require active or sequela codes instead. For example, for a resident with a history of a CVA with residual speech deficits, a sequela code should be used versus a personal history code. A query addressed to the physician/NPP to determine the underlying etiology of a symptom or condition may be necessary.

Another issue with “history of” codes relies on electronic health record (EHR) checkboxes labeled “history of” versus using the actual “history of” ICD-10-CM code for a resolved condition. If a code is available for a personal history of that condition, the active condition code should be resolved in the EHR. The ICD-10-CM code for history should be added. 

5. Confusion Between Acute and Chronic Conditions

Residents in LTC frequently experience acute exacerbations of chronic conditions. Coding errors occur when only the chronic condition is reported or when the acute component is either missed or miscoded. Conditions such as acute on chronic heart failure, acute kidney failure superimposed on CKD, or acute exacerbations of COPD require careful review of physician/NPP documentation. In many cases, both the acute and chronic conditions must be coded to fully reflect the resident’s status. When documentation is unclear, a provider query is needed. 

6. Incomplete Dementia Coding

Dementia is prevalent in LTC but often coded without the required specificity. ICD-10-CM classifies dementia by type, severity, and, in some cases, associated behavioral disturbances. Using unspecified dementia codes when severity or etiology is documented undermines data accuracy. Additionally, dementia due to underlying conditions such as Alzheimer’s disease or other etiologies requires an additional dementia ICD-10-CM code and correct sequencing. Facilities should encourage providers to document dementia type, cause, and severity as part of routine assessments. Coders should ensure the most specific condition is reported.

7. Misunderstanding the “With” Coding Convention

The ICD-10-CM “with” coding convention continues to cause confusion in LTC. Certain conditions—most notably, hypertension with heart disease or CKD, and diabetes with various complications—are presumed to be related based on the presence of the conditions in the medical record, even if the provider does not explicitly document a causal relationship.

Facilities often incorrectly code these conditions separately, rather than using the appropriate combination code (e.g., using I10, hypertension, with a separate heart disease code instead of the combination code of I11). Unless documentation clearly states the conditions are unrelated, coders should apply as many combination codes as there are conditions (e.g., each diabetic complication combination code should be included). When conditions are not linked by “with” or “in” in the Alphabetic Index or Tabular List, physician/NPP documentation must clearly establish the relationship to code them as related. 

8. Following the Tabular List

Accurate coding also depends on a thorough review of the Tabular List, beginning at the three-digit category code (e.g., E11 is the three-digit category code for all Type 2 diabetes codes) and continuing through final code selection. Coders must follow all instructional notes encountered along the way, such as Includes, Excludes1 and Excludes2 notes, Code first, Use additional code, and Code also instructions. These provide mandatory guidance that can affect code choice and sequencing. Skipping this step or relying solely on the Alphabetic Index or notes found only at the final code in the Tabular List increases the risk of incorrect or incomplete coding. All applicable Tabular List instructions must be followed to ensure compliant and accurate reporting.

A Collaborative Approach to Accuracy

Improving accuracy with ICD-10-CM coding requires collaboration among physician/NPPs, nurses, MDS staff, and coders. Support should be provided with ongoing education and clear processes. When documentation accurately reflects the resident’s current condition, coding accuracy follows naturally. The result is stronger compliance, more reliable quality data, and a clearer picture of the complex care delivered every day in LTC settings.

Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, is curriculum development specialist at the American Association of Post-Acute Care Nursing (AAPACN).

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