Certified Risk Adjustment Coder (CRC)

How is conflicting information in a medical record resolved?

1. The conflicting information is deleted.

2. The provider is queried and a late entry is created.

3. A committee reviews and approves the changes.

4. Such conflicts are ignored unless they affect diagnosis coding.

The correct answer is: The provider is queried and a late entry is created.

When conflicting information arises in a medical record, the proper method of resolution involves querying the provider to clarify the discrepancies. This process ensures that the information accurately reflects the patient’s clinical situation and helps maintain the integrity of the medical record. Once the provider responds with the necessary clarification, a late entry may be made to document the correction or additional information provided by the provider. This approach not only helps in resolving the conflict but also supports accurate coding, which is essential for risk adjustment and proper healthcare billing. The other methods mentioned do not align with standard practices in resolving conflicts. Deleting conflicting information could lead to incomplete records and present legal issues. A committee reviewing and approving changes could be overly bureaucratic for simple discrepancies and doesn’t directly address the need for clarification from the original source of the information. Ignoring conflicts unless they affect diagnosis coding undermines the importance of accurate documentation and could lead to incorrect coding and potential compliance issues. Thus, promptly querying the provider and documenting the resolution is the most appropriate and effective strategy.