Clinical Documentation Integrity Golden Rules

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    • 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

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