• In general, medical coding can be drawn from documentation from any healthcare provider (consultants, residents, nurse practitioners, physician assistants, etc.).
• If there is a documentation conflict between two physicians, a Clinical Documentation Improvement specialist will look for clarification from the patient's admitting physician, as that person is responsible for the final diagnosis.
• Consider the following dimensions when documenting a patient's conditions:
  • Where (site and laterality)
  • Specificity (the most detailed diagnosis to match the patient’s condition)
  • Timing (acute or chronic)
  • Manifestations
  • Stage, and
  • Status (e.g., new, unchanged, improving, resolving)
• Link abnormal laboratory or imaging results to the underlying cause (e.g., hyponatremia is due to the patient's hepatic failure). Coders are unable to code from lab or radiology reports. Your diagnoses must be documented separately from the radiology/lab report as a medical problem in your assessment & plan. (e.g., # Epigastric pain: CT shows cholelithiasis, Surgical consult placed [good]. # Cholelithiasis noted on CT : Surgical consult placed [not good] )
• Underdosing is when a patient takes less of a medication than prescribed by a provider. If the patient has a relapse or exacerbation of a medical condition as the result of not taking the medication as prescribed, document
  • the medical condition and
  • the prescribed medication that was not taken as directed.
• Whenever possible, attribute a patient's clinical presentation to an underlying condition (e.g., the patient's shortness of breath is due to ...)

Click here for documentation improvement tactics for pediatricians. Here is the CMS website with additional ICD-10 information for physicians.

Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.

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