Provider tips for achieving accurate diagnosis, documentation & coding.
Posted 02/24/26
Documentation tips.
Accurate diagnosis, documentation, and coding (ADDC) supports continuity of care, quality reporting, and appropriate risk capture. Providers should apply documentation best practices at each patient encounter.
Accuracy: Ensure diagnosis codes reflect the documented diagnostic statement for each condition and keep the problem list current. If a condition is historical or resolved, use the appropriate history code.
Specificity: Document to the highest level of known specificity for each condition (e.g., type of heart failure, severity of major depressive disorder, laterality of hemiplegia).
Consistency: Document the treatment and management plan for each condition, linking medications to the corresponding diagnosis and addressing relevant lab results or diagnostic findings.
Support and contact.
Documentation should reflect the complexity of the patient’s care. Clear, specific, and consistent documentation supports accurate diagnostic capture and reliable quality reporting.
For additional documentation and coding support, providers may contact the ADDC team at [email protected].
