Medical Risk Adjustment Toolkit

How To Improve Coding and Documentation

1. Document and code disease interactions.

2. Document and code coexisting current conditions.

3. List the first ICD-10 diagnostic code for the diagnosis, condition and problem relating to the visit or encounter. Then, list additional codes that describe any coexisting conditions.

4. Do not code treated conditions such as a pregnancy or another condition that has resolved. History codes can be used as secondary when a condition such as diabetes impacts treatment.

5. Providers must categorize treated conditions appropriately within the patient’s medical history section.

6. Current diagnoses can come from anywhere in the note but must be supported by a provider’s documentation.

7. Ideally, review all the medical decision-making. Ensure a patient’s medical history, the exam portion, and/or the assessment and plan include valid diagnoses.

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