Documentation and Compliance
This domain tests the boundary between coding what is documented and coding what you believe to be true. Every code you submit must be supported by a compliant, dated, signed record from the collection year.
Acceptable sources and evidence
Documentation must come from a face-to-face encounter with an acceptable provider type during the data collection year, and it must show the condition was assessed or managed. Problem lists, past medical history copied forward, and health risk assessment questionnaires are not sufficient sources for risk-adjusting diagnoses. Laboratory values and radiology impressions alone do not establish a diagnosis; the treating provider must state it.
Compliant querying
When the record is ambiguous, query. A compliant query is non-leading, cites the clinical indicators, offers clinically reasonable options, and is closed-loop: the provider must document the response in the record. "Did you forget to document CHF?" is leading. "The note documents dyspnea and a BNP of 900; please clarify whether heart failure is present and, if so, its type and acuity" is compliant.
Worked example
A chart shows "PMH: COPD, MDD, CAD" in the history section with no assessment or plan for any of the three at this encounter. None is codeable for risk adjustment from this visit. The coder queries for whether COPD is current and, if so, whether with exacerbation, and whether depression is current and its severity. If the provider answers in the record, the clarified diagnoses may be coded from that encounter; if the answer never reaches the chart, nothing is submitted. Note that CAD is not a risk-adjusting diagnosis in the model, so clarifying it adds no payment even when confirmed.
Traps that cost marks
- Leading queries, or accepting an answer from someone other than the treating provider.
- Copy-forward text identical year after year with no tailored plan - a classic RADV finding.
- Submitting a diagnosis documented only as "history of" on a consult.
- Coding laterality, stage or type the record does not state.
- Ignoring signature and credential requirements, or accepting an unsigned note.