Medical Record Review, Abstraction, and Documentation Capture
What a reviewer can accept
A risk-adjustment abstraction is only as good as its source document. The diagnosis must be documented by an acceptable provider - for example a physician or qualified non-physician practitioner - in a face-to-face encounter dated within the payment or data year, and the record must be legible and authenticated by signature or equivalent electronic attestation.
The problem list alone, a lab value, a medication list, or a billing claim is not sufficient support; the note itself must link the condition to assessment and care. Reviewers abstract the condition, date of service, provider, and code, and retain an audit trail. Queries should resolve ambiguity before submission.
Traps: accepting a note dated outside the year; counting a "history of" statement; using an unsigned or cloned note; assuming a specialist consult outweighs the primary note; and coding from the superbill rather than the record. Reviewers should also watch for copy-forward documentation that repeats stale findings without current evaluation.
Rule of thumb: if you cannot point to the note text that diagnoses and manages the condition, do not abstract it. Worked example: the problem list says "COPD," but the visit note only refills an inhaler with no assessment or plan. The reviewer should query the provider or leave the condition uncaptured.