Accurate, specific documentation helps ensure coding reflects the full complexity of a patient’s health status. MVP has a quick-reference resource that highlights documentation and coding tips for common diagnoses such as diabetes, chronic kidney disease, COPD, heart failure, cancer, heart disease, and major depressive disorder.

Key reminders include documenting status, severity, stage, complications, and related conditions, as well as supporting each diagnosis with a clear assessment and plan. The guide also encourages providers to address chronic conditions annually, avoid ambiguous language, and keep problem lists updated.

You can find these documentation and coding tips here.