Medical Record Documentation & Abstraction Flashcards
6 cards from real CRC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Medical Record Documentation & Abstraction flashcards as text
A CRC is abstracting from a multi-provider encounter. Which documentation sources can be used for risk adjustment coding?
Answer: Documentation from any qualified provider with a face-to-face encounter
Diagnoses can be coded from any qualified healthcare provider (MD, DO, NP, PA) who had a face-to-face encounter.
An addendum is added 45 days after the original encounter. Under what conditions is this acceptable for risk adjustment?
Answer: Acceptable if it clarifies the original note, is signed and dated, and the original supports a face-to-face evaluation
Late addenda can be acceptable if they meet documentation integrity standards and the original note supports a qualifying encounter.
A discharge summary lists 12 diagnosis codes but only 8 have supporting narrative. How should the CRC handle the 4 unsupported codes?
Answer: Code only the 8 supported by narrative documentation
Codes without narrative support may not survive RADV audit scrutiny. Code the 8 supported conditions and consider querying for the remaining 4.
An EHR assessment section contains 20+ conditions on the problem list but the plan section only addresses 5. Which conditions can be coded for risk adjustment?
Answer: Only the 5 conditions addressed in the plan section
Conditions addressed in the plan demonstrate active provider engagement. Problem list conditions not addressed may not meet the standard.
A specialist defers final diagnosis to the referring physician but documents extensive evaluation findings. Can the specialist's findings be used?
Answer: Yes, conditions the specialist assessed and documented can be coded
A specialist who performs a face-to-face evaluation has generated codable documentation, even if they defer ongoing management.
In a home health encounter, which documentation supports risk adjustment coding?
Answer: The physician's certification and face-to-face encounter notes support coding; nursing documentation alone does not
The physician's face-to-face encounter documentation supports risk adjustment. Nursing documentation alone lacks diagnostic authority for HCC-mappable conditions.