Clinical Documentation Integrity Golden Rules

• 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

Download the complete tip, Clinical Documentation Integrity Golden Rules.