ICD-10-CM Disease and Injury codes describe causes of illness or clinical symptoms exhibited by the patient, and codes assigned must be supported by _____.

The requirement that codes assigned in ICD-10-CM must be supported by documentation in patient records is crucial to ensure accurate coding and billing practices. This means that for any diagnosis, the medical record must contain sufficient detail that justifies the use of that specific code. Documentation acts as the foundation for the coding process; it provides the necessary clinical information regarding the patient’s condition, treatment, and the rationale for the care provided.

Accurate documentation is essential not only for coding but also for continuity of care, quality assessment, and legal purposes. It ensures that healthcare providers can support their clinical decisions and that insurers can validate claims based on the services rendered to the patient. Without appropriate documentation, there may be discrepancies between what is coded and the actual clinical picture, which could lead to denials of claims or insufficient reimbursement. Hence, coding relies heavily on comprehensive and precise documentation in patient records.