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 chart contains photocopied documents from an outside provider. Can these be used for risk adjustment coding?
Answer: They can be used if incorporated into the record and acknowledged by the treating provider
External documents can support coding if the treating provider acknowledges, reviews, or references the information.
A provider's assessment says 'COPD' but pulmonary function tests show normal spirometry. How should the CRC handle this?
Answer: Query the provider to reconcile the assessment with test results
When documentation conflicts with objective test results, query the provider. Normal spirometry raises questions about the COPD diagnosis.
What documentation requirements must a telehealth encounter meet for risk adjustment?
Answer: Must document real-time audio-visual interaction, use qualifying modifiers, and meet same standards as in-person visits
Qualifying telehealth encounters must include real-time audio-visual communication and meet the same documentation standards.
An in-home Health Risk Assessment identifies conditions not in PCP records. Can these be coded for risk adjustment?
Answer: HRA findings from a qualifying face-to-face encounter can be coded if supported by clinical evaluation
Documentation must include clinical assessment supporting each diagnosis, not just checkboxes or patient self-reports.
A physician uses extensive non-standard abbreviations. What abstraction risk does this create?
Answer: Abbreviations may be ambiguous, misinterpreted, or not clearly support a specific diagnosis for HCC coding
Non-standard abbreviations create risk because RADV auditors may interpret them differently than the abstractor.
During retrospective review, a CRC discovers entries dated after the payment year cutoff that add diagnoses to prior year encounters. Are these valid?
Answer: Late entries must be evaluated carefully; timing relative to audit notifications is a key credibility factor
Legitimate late entries can be valid, but entries timed with audits or year-end sweeps raise serious compliance concerns.