CRC Medical Record Documentation & Abstraction 2

Question 1

A CRC is abstracting from a multi-provider encounter. Which documentation sources can be used for risk adjustment coding?

Accepted Answer

Documentation from any qualified provider with a face-to-face encounter

Answer

Only the attending physician's documentation

Answer

Only the billing provider's documentation

Answer

All clinical staff including nurses and medical assistants

Question 2

An addendum is added 45 days after the original encounter. Under what conditions is this acceptable for risk adjustment?

Accepted Answer

Acceptable if it clarifies the original note, is signed and dated, and the original supports a face-to-face evaluation

Answer

Addenda older than 24 hours are never acceptable

Answer

All addenda are automatically acceptable

Answer

Acceptable only if added before claim submission

Question 3

A discharge summary lists 12 diagnosis codes but only 8 have supporting narrative. How should the CRC handle the 4 unsupported codes?

Accepted Answer

Code only the 8 supported by narrative documentation

Answer

Code all 12 since they appear in the official discharge summary

Answer

Code all 12 but flag the 4 for a provider query

Answer

Code none since the documentation is incomplete

Question 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?

Accepted Answer

Only the 5 conditions addressed in the plan section

Answer

All 20+ conditions on the problem list

Answer

All conditions ever treated

Answer

Only conditions appearing in both sections

Question 5

A specialist defers final diagnosis to the referring physician but documents extensive evaluation findings. Can the specialist's findings be used?

Accepted Answer

Yes, conditions the specialist assessed and documented can be coded

Answer

No, the specialist deferred the diagnosis

Answer

Only if the PCP subsequently confirms

Answer

Only procedure codes can be submitted

Question 6

In a home health encounter, which documentation supports risk adjustment coding?

Accepted Answer

The physician's certification and face-to-face encounter notes support coding; nursing documentation alone does not

Answer

Nurse's documentation is sufficient since she provided direct care

Answer

Both equally support coding

Answer

Home health encounters do not qualify