CRC Medical Record Documentation & Abstraction 2 — Questions and Answers
Question 1: A CRC is abstracting from a multi-provider encounter. Which documentation sources can be used for risk adjustment coding?
- Only the attending physician's documentation
- Documentation from any qualified provider with a face-to-face encounter (Correct answer)
- Only the billing provider's documentation
- All clinical staff including nurses and medical assistants
Correct 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.
Nursing and medical assistant documentation cannot support diagnosis coding, with limited exceptions like BMI documentation.
Question 2: An addendum is added 45 days after the original encounter. Under what conditions is this acceptable for risk adjustment?
- Addenda older than 24 hours are never acceptable
- Acceptable if it clarifies the original note, is signed and dated, and the original supports a face-to-face evaluation (Correct answer)
- All addenda are automatically acceptable
- Acceptable only if added before claim submission
Correct 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.
For RADV, late addenda are scrutinized more heavily. Best practice is timely documentation at the time of service.
Question 3: A discharge summary lists 12 diagnosis codes but only 8 have supporting narrative. How should the CRC handle the 4 unsupported codes?
- Code all 12 since they appear in the official discharge summary
- Code only the 8 supported by narrative documentation (Correct answer)
- Code all 12 but flag the 4 for a provider query
- Code none since the documentation is incomplete
Correct 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.
Codes auto-populated from problem lists without provider assessment are high-risk for deletion during audit.
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?
- All 20+ conditions on the problem list
- Only the 5 conditions addressed in the plan section (Correct answer)
- All conditions ever treated
- Only conditions appearing in both sections
Correct 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.
EHR auto-populated problem lists are a significant source of risk adjustment audit risk.
Question 5: A specialist defers final diagnosis to the referring physician but documents extensive evaluation findings. Can the specialist's findings be used?
- No, the specialist deferred the diagnosis
- Yes, conditions the specialist assessed and documented can be coded (Correct answer)
- Only if the PCP subsequently confirms
- Only procedure codes can be submitted
Correct 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.
Specialists often document with greater specificity, resulting in more specific diagnoses that map to higher-severity HCCs.
Question 6: In a home health encounter, which documentation supports risk adjustment coding?
- Nurse's documentation is sufficient since she provided direct care
- The physician's certification and face-to-face encounter notes support coding; nursing documentation alone does not (Correct answer)
- Both equally support coding
- Home health encounters do not qualify
Correct 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.
CRC candidates working with home health records must understand this sourcing hierarchy.
CRC Medical Record Documentation & Abstraction 2
A CRC is abstracting from a multi-provider encounter.
Which documentation sources can be used for risk adjustment coding?