Did you know that detailed documentation leads to accurate coding, and accurate coding leads to appropriate and timely claims payments for physicians and hospitals. More importantly, it can lead to better and more effective patient care.

52% of all denials that are medical necessity related are the result of not being detailed in the clinical documentation to reflect appropriate diagnoses being treated. In order to be successful, it is important now more than ever to go from documentation good, to better and ultimately the best.

Stages of documenting your diagnoses (from okay to best):

Not meaningful: diagnosis only

Good: Diagnosis + status (stable, worsening, controlled)

Better: Diagnosis + status + treatment (plan)

Best: Diagnosis + status + treatment + thought process/associated risk and conditions

Here is an example of the above, put into practice:

Not meaningful: “Diabetes”

Good: “Stable Diabetes”

Better: “Diabetes stable on Metformin <insert dosage>”

Best: “Diabetes stable on Metformin <insert dosage>, will monitor kidney function due to risk of CKD”