All PlansDocumentationMedium impact
Hospital Medical Record Documentation
Missouri Medicaid (MO HealthNet)·MO·Provider Notice
Effective date
Jun 16, 2014
We identified it
Jun 20, 2026
Summary
This policy emphasizes the critical importance of complete and accurate medical record documentation for proper ICD-9 diagnosis coding and reporting. It requires healthcare providers and coders to work together to ensure thorough documentation that supports determinations of whether conditions were present on admission.
Action Required
Providers must ensure complete and consistent documentation in medical records for all patient encounters. Work with coding staff to verify documentation supports accurate ICD-9 code assignment and present-on-admission determinations. Review current documentation practices to identify gaps that could affect coding accuracy.