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5 Easy Ways to Improve Documentation

Feb 15, 2024 | News

Stay out of harm’s way when it comes to risk adjustment compliance.  Granite GRC Consulting presents a series of monthly articles for the Pennsylvania Medical Society’s DOSE newsletter.  Visit to learn more.

Provider offices have invested in decades of documentation improvement to advance the quality and accuracy of CPT code reporting. In today’s managed care environment, risk adjustment demands that equal focus be placed on documentation of diagnoses, and abstraction of correct ICD-10-CM codes. There are some very simple steps providers can take to greatly improve documentation and coding, which can result in more clarity in the medical record, greater accuracy in diagnostic reporting, and reduced risk in an audit.

The twin goals of documentation are to tell the patient’s story, and tell it completely, and to enable abstraction of accurate diagnoses by including enough information to achieve specificity in coding. Detailed documentation protects against malpractice and other adverse results, allows for abstraction of the most appropriate diagnosis code, and ensures providers have the complete picture of their patient for future encounters. Knowing and including information pertinent to code selection protects against miscoding. Included below are five simple methods for medical documentation improvement.

  1. Every diagnosis is your responsibility. A provider needn’t be the primary manager of a comorbidity to document and code it. If the patient’s comorbidity affects the treatment plan or complicates the patient’s presenting problem, document it. Similarly, if managing only a portion of a patient’s diagnosis, any complications of that diagnosis should also be reported, even when not managed by you (eg, the provider manages the patient’s diabetes, but not the patient’s diabetic CKD. Even so, the CKD should be detailed in the note as it informs on the severity of the diabetes.).
  2. Stop writing “history of.” ICD-10-CM guidelines say that past history should not be reported as an active condition. Therefore, ongoing problems should be described as just that: “the patient’s worsening pulmonary insufficiency” or “long-standing pulmonary insufficiency” is clear. “History of pulmonary insufficiency” could describe something that has resolved.
  3. Start adding “due to” after each diagnosis. Rather than just noting acute blood loss anemia, document the anemia due to hemorrhage, due to esophageal varices, due to portal hypertension, due to cirrhosis of the liver, due to active alcoholism. In this way, the complete clinical picture van be understood.
  4. Yesterday’s work doesn’t count. Previous documentation doesn’t count within the context of today’s encounter. CMS requires documentation in today’s note any diagnosis reported for today’s visit. For example, a patient with COPD is seen today for pneumonia. Although previous notes and today’s problem list specify COPD, if this condition isn’t described in today’s encounter, the complexity of the patient’s new-onset pneumonia would be missed in abstraction. CMS doesn’t allow us to code from the problem list.
  5. Avoid “note bloat.” Large blocks of past documentation pulled into today’s note from a previous encounter are of little value to coding if not amended to reflect changes since the last encounter. Keep your notes lean by including only today’s findings and observations.

These simple suggestions can make documentation easier and more accurate. Next month, we will look at some ways to ensure your documentation will lead to the proper ICD-10-CM when abstracted. After that, we will look at some of the common errors seen in risk adjustment documentation and coding.

Written by Sheri Poe Bernard, CRC, CPC, CDEO, CCS-P, Director, Risk Adjustment Assessment and Compliance.  Granite GRC can help navigate your toughest risk adjustment challenges.  Contact us at, or call (717) 556-1090.