- Document DIAGNOSES not SIGNS/SYMPTOMS
- Signs and symptoms do not adequately risk adjust quality metrics
- “Possible”, “Probable”, “Suspected” and “Likely” diagnoses are acceptable
- Must be included in the DC summary to be coded
- Document queried diagnoses in the medical record
- Document ALL DIAGNOSES on the DC summary
- Ensures diagnoses are coded
- Only coded diagnoses are used to risk adjust quality metrics
- Document “Present On Admission” (POA) when appropriate
- Quality metrics risk adjust with diagnoses captured as POA
- Only diagnoses POA are eligible to be the principal diagnosis
- POA status can be assigned at any time
- Avoid “history of” → instead consider “chronic” or “as a late effect”
- “History of” is considered a remote condition which is not active nor chronic
- Avoid the term “versus”
- Coders are not allowed to interpret documentation
- When “versus” is documented the diagnosis is unclea
- Avoid the term “to cover” → instead use the term “to treat”
- “To cover” is an ambiguous term that requires a query
Documentation Tips
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