Diagnosis Coding Documentation Best Practices

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Medical record documentation of patient diagnoses that is clear, concise, and described to the highest level of specificity facilitates:

  • Quality patient care with better outcomes
  • Accurate diagnosis code assignment
  • Appropriate and timely health care provider payment for service rendered

History versus active

  • Please do not use “history” to describe a current or chronic condition that is still present
  • If a condition is in remission, please describe the condition as in remission instead of using the word “history”

Be watchful when using template that might introduce contradictory and/or conflicting information in the progress note. Many templates may default to “normal” value for review of systems (ROS) or in the physical exam which may conflict with information in the HPI or in the assessment. For example, a patient with severe major depression and PHQ-9 score of 23, but ROS states “patient denies depression” can be problematic to support the diagnosis for severe major depression.

Provide a clear picture of patient’s health status

Providers should document all conditions that impacted the patient’s care on the date of service. Also, all co-morbid conditions that currently exist should be documented and address in the plan. It is a good idea to include a specific treatment plan for each diagnosis such as status (stable, worsened, improved) medication changes, dietary recommendations, scheduling of diagnostic testing, etc.

By applying the above tips can help your practice achieve better outcomes for your patients and more accurate reimbursement for your value-risk contracts. At Symbion Coding, we believe in helping medical practices, MSO, ACO achieve accurate reimbursement. Please give us a call at (800) 672-8149 or we can meet in person at a place and time that is convenient for you.


Founded in 2015, Symbion Coding is a dynamic group of coding and HIM experts, working to create solutions to help medical practices, ACO and MSO achieve optimal risk score accuracy. We focus primarily on helping healthcare providers with value-risk contracts to achieve better financial results in today’s healthcare new payment models.

Jean Delva
Founder & CEO of Symbion Coding, Inc.
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