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

Diagnoses can be coded from any qualified healthcare provider (MD, DO, NP, PA) who had a face-to-face encounter.

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

Late addenda can be acceptable if they meet documentation integrity standards and the original note supports a qualifying encounter.

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

Codes without narrative support may not survive RADV audit scrutiny. Code the 8 supported conditions and consider querying for the remaining 4.

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

Conditions addressed in the plan demonstrate active provider engagement. Problem list conditions not addressed may not meet the standard.

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

A specialist who performs a face-to-face evaluation has generated codable documentation, even if they defer ongoing management.

(CRC) Certified Risk Adjustment Coder Practice Test

(CRC) Certified Risk Adjustment Coder Practice Test

CRC Medical Record Documentation & Abstraction 2