Primary Care Coding Alert

Reframing documentation as part of clinical care can positively impact everyone.

There are three pillars of a thorough assessment and treatment plan in comprehensive documentation. Primary care providers see myriad conditions in varying severities, and thoroughly documenting the assessment and treatment plan of each encounter is crucial to accurate capture.

Here are some tips on exactly what to focus on to improve documentation of assessment and treatment plan, courtesy of a 2026 AAPC DOCUCON session from Kristen Viviano, MHA, CPC, CRC, AAPC Approved Instructor: “What a Thorough Assessment Plan Looks Like.”

Understand the 3 Pillars

Problem-oriented documentation is making sure that each condition is addressed. “Each active condition gets its own addressed entry. It’s not bundled together with something else, it’s not implied, it’s not tucked into a little paragraph somewhere else, hidden away. Each problem gets individually acknowledged,” Viviano said.

Specificity is crucial for capturing a patient’s clinical condition, as well as allowing coders to select and report the most appropriate code. “Specificity is the difference between a diagnosis that’s just named and a diagnosis that’s described. ‘Diabetes’ is named; ‘Type 2 diabetes mellitus uncontrolled with diabetic neuropathy’ is described. Those aren’t the same things from a coding standpoint, and they aren’t the same thing from a clinical standpoint either, which is important to remember,” she said.

Making sure to note any relationships between diagnoses is also important. “Diagnosis linkage is where conditions that are related to each other — complication, a contributing factor, a manifestation — are connected in the documentation. Again, not implied, not obvious to only the clinician, but written down,” she said.

These three things aren’t independent of one another. “A note can be problem-oriented but still unspecific. It can be specific but fail to link conditions. When all three are present, that’s when we have a note that holds up to coding, to auditing, and showing the actual clinical picture of the patient,” Viviano explained.

The documentation should show that the provider considered each relevant condition. “It doesn’t have to be elaborate, it can be as simple as ‘A1C is stable, continue current regimen’ or ‘blood pressure improved, no medication changes.’ But it can’t be silent. The provider saw the patient, reviewed the condition, and made a clinical decision. Even if the decision is to do nothing and change nothing, that decision still needs to be in the note.”

Give Assessed Conditions Current Context

However, conditions that are mentioned only in the history of present illness (HPI) or review of systems need to be documented to support reporting for the encounter. “If a provider mentions diabetes in the HPI, but they never address how that impacted this visit, what they considered for it on this visit, the diagnosis is not supported for coding. It’s there, but it’s not addressed. That distinction that matters hugely in an audit,” she said.

Copying documentation forward or copying and pasting documentation from a prior encounter form into a current one is problematic for the patient’s health narrative and for coders reporting the visit.

The documentation was highly specific and accurate when it was written, but it may not reflect the patient’s current state. “It not only fails the coders, because we are trying to code what is currently happening with the patient, but it’s actively creating audit risk,” she said. “You are essentially coding from a clinical picture that might not be true anymore.”

A simple way of improving documentation is making sure providers aim for description rather than mere mention. For example, “chronic kidney disease” may be listed in the record as “CKD,” but that doesn’t provide enough information for coders to accurately report a condition — or show what the patient is experiencing. However, a provider recording “CKD stage 3b, due to hypertensive nephropathy” is specific enough to illustrate the patient’s condition — and for a coder to select a more exact code to capture the condition.

Even if the provider does their own coding, the documentation still needs to support the reporting. Viviano said she always errs on the side of having it documented rather than risking scrutiny from a payer.

Talk to Payers in Their Language

Knowing what good documentation looks like versus getting a provider to produce good documentation are two entirely different feats. In her experience, providers tend not to respond well to coding language. “The second you walk into a physician’s office and say ‘We need more specific codes’ or ‘This HCC [hierarchical condition category] is not going to map without more detail,’ you’ve lost them,” she said.

Most providers pursued the education necessary to take care of patients, not to become certified in coding; they don’t want to think about hierarchical condition categories, they want to treat patients, she said. Reframing the conversation in terms of clinical accuracy instead of coding accuracy can help get your point across.

For example, asking the provider “Does the documentation reflect how sick this patient truly is?” can help them understand whether what they recorded is sufficient.

“We don’t want to lead the providers and have them making coding decisions based on HCCs or based on risk scores. We need to show them that it is impactful from a clinical standpoint. We want to try saying, ‘The note should show what you’re managing, not just that something is being managed,’” she said.

This approach can really resonate with providers who take pride in their clinical work. “They’re doing the work, the documentation just doesn’t reflect it,” she explained. While the saying “think in ink” to emphasize that work not documented didn’t happen is easy to remember and communicate, it centers the problem in coding rather than clinical accuracy, she said.

Helping providers understand how their documentation of a patient’s condition — as well as their clinical assessment and treatment — during an encounter is part of excellent clinical care is crucial to capturing the reimbursement earned for their work.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC